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A    MANUAL 


OF 


OPERATIVE   SURGERY. 


BY 

FREDERICK   TREVES,  F.R.C.S., 

SURGEON  TO  AM)   LECTURER  ON   ANATOMY  AT   THE    LONDON  HOSPITAL  ;    MEMBER   OF    THE   BOARD 
OF  EXAMINERS  OF  THE  ROYAL  COLLEGE  OF  SURGEONS. 


WITH  422   ILLUSTRATIONS. 


VOL   I. 

OKNERAL   PRINCIPLES — ANESTHETICS — OPERATIONS   UPON   ARTERIES 

AND   NERVES — AMPUTATIONS — EXCISIONS — OPERATIONS 

UPON   BONES,   JOINTS,    AND   TENDONS. 


PHILADELPHIA: 

LEA   BROTHERS   &   CO. 

1892. 


PREFACE. 


The  present  work  concerns  itself  solely  with  the  practical 
aspects  of  treatment  by  operation,  with  the  technical  details 
of  operative  surgery,  and  with  such  part  of  the  surgeon's  work 
us  comes  within  the  limits  of  a  handicraft. 

With  the  indications  for  operating  I  have  not  dealt,  nor 
have  I  entered  into  the  subtle  questions,  the  anxious  reason- 
ings, the  spectral  doubts,  which  lie  without  the  operating 
theatre. 

Into  the  mysteries  of  surgical  statistics  I  have  ventured 
also  with  but  reverent  caution. 

For  the  selection — out  of  the  vast  and  bewilderingf  col- 
lection  provided  by  the  literature  of  Surgery — of  particular 
methods  of  operating  I  must  hold  myself  answerable.  I  have 
selected  such  measures  as  have  appeared  to  me  to  be  the  best, 
and  have  made  no  attempt  at  encyclopaedic  completeness. 

The  majority  of  the  descriptions  are  founded  upon  per- 
sonal experience  in  the  operating  theatre,  and  upon  repeated 
operations  on  the  dead.  The  account  of  such  particular 
methods  as  are  associated  with  the  names  of  individual 
surgeons  I  have  endeavoured  to  give  in  the  actual  words 
of  the  authors. 

In  each  section  I  have  included  details  as  to  the  pre- 
paration of  the  patient  and  the  after-treatment  of  the  case, 
and  have  discussed  the  comparative  merits  of  the  various 
operations  described. 

The  illustrations  have  been  executed  by  Mr.  Charles 
Berjeau,  to  whose  artistic  skill  and  much-tried  patience  I  am 
greatly  indebted.     The   majority  of  them   have   been   made 


vi  OPERATIVE    SURGERY. 

from  sketches  of  my  own.  Sucli  as  have  been  derived 
from  other  sources  are,  I  hope,  fully  acknowledged. 

I  am  much  obliged  to  the  proprietors  of  the  Lancet  for 
kindly  lending  nie  the  blocks  from  which  Figs.  237  and  238 
are  printed. 

The  figures  of  instruments  are  for  the  most  part  copied 
from  Weiss's  Catalogue. 

The  whole  of  such  leisure  as  I  could  obtain  during  the 
last  four  years  has  been  devoted  to  the  writing  of  this  book, 
and  I  have  done  my  best  to  render  it  complete  as  a  Practical 
Manual  of  Operative  Surgery :  but  I  would  rather  rely  upon 
the  reader's  indulgence  than  upon  these  extenuating  circum- 
stances when  the  many  shortcomings  of  the  book  have  to  be 
judged. 


6,  Wimpole  Street,  London. 
October,  1891. 


CONTENTS, 


fart  I. 

GENERAL   PEINCIPLES. 


CHAP. 

I. — The  Patient 


II. — The  Opekator         .... 
III. — The  Operating  Room 
IV.— The  Instruments  and  Accessories 

V. — The  Elements  of  Operative  Surge ky 
VI. — The  After-Tkeatment  of  the  Wound 


page 
1 

26 

31 

36 

49 

67 


fart   II. 

THE    ADMINISTRATION    OF   ANAESTHETICS. 

I. — The  Anesthetic  Agents   most  Commonly  Employed:   their 
Properties,  and  the  Effects  which  they  produce  when 
administered  to  Normal  Adults        .....       71 
II. — Modifications  in  the  Effect  of  the  An.t;sthetic  Dependent 

upon  Physical  Condition,  etc 78 

III. — Preparation  of  the  Patient  for  the  Administration  of  the 

An.«sthetic.         .........       81 

IV. — The  Selection  of  the  An.?3Sthetic 82 

V. — The  Administration  of  the  Anaesthetic       ....       84 
VI. — The  Chief  Difficulties  and  Dangers  connected  with  the 

AN.3LSTHETIC    StATE  :    THEIR    MANAGEMENT  AND   TREATMENT     .  91 


fart  III. 

THE    LIGATURE    OF    ARTERIES. 
I.  — General  Considerations        .... 

IT. T>IOATURE    OF    THE    Ap.TERIES  OF    THE    UpPER    LiMB 


99 
114 


OPE  RAT  WE    SURGERY. 

CHAP.  P-i-OE 

III. — Ligature  of  the  Arteries  of  the  Head  and  Neck    .         .     136 

IV. — Ligature  of  the  Arteries  of  the  Lower  Limb  .         .         .     172 

V. — Ligature  of  the  Iliac  Arteries,  and  of  the  Abdominal  Aorta     198 


IP  art  lY. 

OPERATIONS    UPON    NERVES. 

I. — Introductory  .........  221 

n. — Operations  upon  the  Nebves  of  the  Head  and  Neck        .  227 

III. — Oper-^tions  upon  the  Nertes  of  the  Upper  Extremity    .  251 

IV. — Operations  upon  the  Nerves  of  the  Lower  Extremity    .  254 


fart  Y. 

AMPUTATIONS, 
I. — The  History  of  the  Opehation    . 
11. — The  Amputation  Stump 
TIT. — The  Controlling  of  Haimokrhage  during  the   Operation 
IV. — The  Instruments  Required  in  Amputation  . 
V. — Methods  of  Performing  Amputation   .... 
VI. — The  Selection  of  Methods  for  Amputating 
Vn. — General  Points  in  the  Performance  of  Amputations 

Vin. — The  Future  of  the  Stump 

IX. — The  Mortality  after  Amputation        .... 
X. — ^Amputation  of    the  Fingers  and   Thumb — General   Con 

siderations 

XI. — Amputation  or  Disarticulation  of  the  Phalanges  of  the 

Fingers 

Xn. — Disarticulation  of  Fingers  at  the  Metacarpo-phalangeal 

Joints 

XIII. — Amputations  and  Disarticulations  of  the  Thumb 
XIV. — Amputations   of  the  Fingers  and  Thumb,  together   wit 
Portions  of  the  Metacarpus 
XV. — Disarticulation  at  the  Wrist-joint 
XVI. — Amputation  of  the  Forearm 
XVII. — Disarticulation  at  the  Elhow-joint 
XVIII. — Amputation  of  the  Arm 


259 
266 

277 
283 
287 
299 
304 
310 
314 

317 

324 

329 
334 

336 
345 
356 
363 
373 


CONTENTS.  is 

CHAP.  PAGE 

XIX. — AMrUTATION    THKOUGH  THE    SuRGICAL    NeCK    OF    THE    HuMEl'.US       380 

XX. — Disarticulation  at  the  Shoulder- joint       ....  383 

XXI. — Amputation  of  the  Upper  Limii,  together  with  the  Scapula  397 

XXII. — Amputation  of  the  Toes 40:! 

XXIII. — Partial  Amputation   of  the  Foot — Amputations   through 

the  Tarso-Metatarsal  Joints    .         .         .         .         .         .41'^ 

XXIV. — Partial   Amputation    of   the   Foot — Amputation   through 

the  Medio-tarsal  Joint     .         .         .         .         .         .         .431 

XXV. — Partial   Amputation   of    the    Foot — Sukastragaloid   Dis- 
articulation       .         .         . 43  j 

XXVE. — Amputation  of  the  Foot       .......  444 

XXVII. — Osteo-Plastic  Resection  of  the  Foot          ....  456 

XXVIII. — Amputation  of  the  Leg 460 

XXIX. — Disarticulation  at  the  Knee-joint      .....  489 

XXX. — Amputation  of  the  Thigh  through   the  Condyles    ,         .  500 

XXXI. — Amputation  of  the  Thigh    .......  509 

XXXII. — Disarticulation  at  the  Hip-joint 524 


fart  YI. 

OPERATIONS    ON    THE    BONES    AND    JOINTS. 


I. 

TI. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 


-Osteotomy       .......-• 

-Osteotomy  for  Faulty  Anchylosis  of  the  Hip-joint 
-Osteotomy  for  Genu  Valgum        .... 


— Osteotomy*  for  Faulty  Anchylosis  of  the  Knee-join 

— Osteotomy  of  the  Tibia         ..... 

—Cuneiform  Osteotomy  for  Inveterate  Club-Foot 

— Operative  Treatment  of  Ununited   Fracture     . 

— Excision  of  Joints  and  Bones      .... 

— Excisions  of  the  Fingers,  Thumb,  and  Metacarpus 

— Excision  of  the  "Wrist  . 

— Excision  of  the  Radius  and  Ulna 

— Excision  of  the  E^bow 

— Excision  of  the  Humerus 

— Excision  of  the   Shoulder 

— Excision  of  the  Clavicle  and   Scapula 

— Excisions  of  the  Toes,  Metatarsus,  and  Tarsus 


549 
562 
565 
573 
575 
580 
585 
595 
610 
614 
628 
630 
646 
647 
657 
665 


OPERATIVE    SURGERY. 


CHAP. 

XVII. — Excision  of  the  Ankle  . 


XVIIL— Excision  of  the  Kneb    . 
XIX. — Excision  of  the  Hip 
XX. — Akthrectomy  or  Erasion  of  a  Joint 
XXL  — Excision  of  the  Upper  Jaw. 
XXII. — Opeuations  upon  the  Upper  Jaw  in   connection  with  the 

Treatment  of  Naso-pharyngeal  Polypus 
XXIII. —Excision  of  the  Lower  Jaw 


PAGE 

672 
6fi0 
694 
709 
715 

729 
742 


IP  art  YIL 

TENOTOMY, 

Includino   Operations   for    the    Division   op    Contracted 
Muscles,  Ligaments,  and  Fascia 


753 


LIST   OF   ILLUSTRATIONS. 


PAGE 

Diagram  showing  Arrangement  of  Surgeon's  Tables 34 

Good  Scalpel :  Bad  Scalpel 38 

Stout  Dissecting  Forceps 39 

Spencer  Wells'  Artery  Forceps  .........       39 

NVakley's  Artery  Forceps 40 

Farabeuf's  Modification  of  Langenbeck's  Retractor    .  ...       41 

Farabeuf's  Retractor 41 

Straight  Triangular-pointed  Suture  Needle :  Half- curved  Suture  Needle  .  42 
Simple  Needle  Holder         ..........       43 

First  Stage  of  the  Surgeon's  Knot 44 

Three  Diagrams  to  Illustrate  the  Holding  of  the  Scalpel   .         .         .         .51 

]\Iode  of  Exposing  a  Tumour  by  Ligature  or  Thread  Retractors  .         .       55 

Method  of  Steadying  the  Margins  of  a  Wound  with  Blunt  Hooks  during 

the  Introduction  of  the  Sutures  ........       59 

Clover's  Inhaler  ...........       84 

Junker's  Inhaler         .         .  • 86 

Skinner's  Mask  and  Chloroform  Drop-Bottle      ......       87 

Cylinders  for  Nitrous  Oxide       .........       88 

Nitrous  Oxide  Apparatus  ..........       89 

Aneurysm  Needle       .         .         . .102 

SjTne's  Aneurysm  Needle  .         .         .         .         .         .         ,         ,         .         .102 

Dupuj'tren's  Aneurysm  Needle  .         .         .         .         .         .         .         .         .103 

Diagrams  Illustrating  the  "  Reef  "  Knot  and  "  Granny  "  Knot  .  .  .  Ill 
Ligature  of  the  Radial  and  Ulnar  Arteries,  and  of  the  Brachial  at  the  Bend 

of  the  Elbow 115 

Ligature  of  the  Right  Radial  at  the  Wrist .116 

Ligature  of  the  Right  Radial  about  the  Middle  Third  of  the  Forearm         .     116 
Ligature  of  the  Right  Ulnar  at  the  Wrist .         .         .         .         .         .         .120 

Ligature  of  the  Right  Ulnar  at  the  Middle  Third  of  the  Forearm       .         .     121 
Transverse  Section  of   the  Forearm  (diagrammatic),  to  show  the  Inter- 
muscular Spaces  about  the  Middle  Third 122 

Ligature  of  the  Right  Brachial  at  the  Bend  of  the  Elbow .  .  .  .  126 
Ligature  of  the  Right  Brachial  at  the  Middle  of  the  Arm  .  .  .  .127 
Ligature  of  the  Brachial  about  the  Middle  of  the  Ann,  and  of  the  Third 

Part  of  the  Axillary 131 

Ligature  of  the  Right  Axillary  Artery  (Third  Tart) 132 

Ligature  of  the  First  Part  of  the  Axillary  Artery,  the  Third  Part  of  the 

Subclavian,  the  Common  Caiotid,  and  the  Lingual       .         .         .         .139 

Ligature  of  the  Right  Subclavian  (Third  Part) _ .     141 

Anatomy  of  the  Vertebral  and  Inferior  Thyroid  Arteries  ....  147 
Ligature  of  the  Right  Common  Carotid  above  the  Omo-hyoid    .         .         .     153 


xii  OPERATIVE    SURGERY. 

PA  OB 

External  Carotid  Arteiy,  natural  size 157 

Lii^ature  of  Wght  External  Carotid 159 

Ligatiu-e  of  Right  Lingual  Aitcrj- 167 

Diagram  to  show  the  Positiou  of   the   Facial,  Temporal,  and   Occipital 

Ai-teries 170 

Ligature  of  the  Anterior  Tibial  Artery,  and  of  the  Doi'salis  Pedis     .         .174 
Ligature  of  Riglit  Anterior  Tibial  Artery  (Upper  Third)    .         .         .         .175 

Ligatui'e  of  Right  Anterior  Tibial  (Lower  Third)       .         .         .         .         .177 

Line  of  the  Popliteal,  Posterior  Tibial,  and  Peroneal  Arteries  (Right  Limb)     179 
Ligature  of  the  Right  Posterior  Tibial  Artery    .         .         .         .         .         .180 

Ligature  of  the  Right  Posterior  Tibial  Arter^'-  (Lower  Third)  .  .  .181 
The  Mode  of  Dividing  the  Soleus  Muscle  in  Ligatm-e  of  the  Posterior 

Tibial  Artery  in  the  Middle  of  the  Calf 182 

Ligature  of  Right  PopUteal  (Lower  Part)  ......      187 

Ligature  of  the  Right  Common  Fomoial  at  the  Base  of  Scarpa's  Triangle  ; 

of  the  Femoral  at  the  Apex  of  Scarpa's  Triangle  and  in  Hunter's  Canal, 

and  of  the  Upper  Part  of  the  Popliteal 190 

ligature  of  Right  Femoral  Artery  in  Hunter's  Canal  ....     193 

Ligature  of  Right  Femoral  Artery  at  Apex  of  Scarpa's  Triangle        .         .194 
Ligature  of  Right  Common  Femoral  at  Base  of  Scarpa's  Triangle     .         .195 
Relation  of  Veins  to  the  Common  Iliac  Ai-teries.         .         .         .         .         .198 

Ligature  of  External  Iliac  Artery:  Ligature  of  Common  Iliac  Artery  .  199 
Ligature  of  Right  External  Iliac  Arter)'    .......     201 

Ligature  of  Right  External  Iliac  Artery 203 

The  Incisions  for  the  Gluteal,  Sciatic,  or  Pudic  Arteries     ....     215 

Hook  used  in  Neurotomy  or  Neurectomy 224 

The  Nerves  of  the  Face  and  their  Relations  to  the  Arteries  of  the  Region.     228 

Tlie  Nerves  of  the  Face  and  of  the  Side  of  the  Head 234 

Diagram  of  the  Third  Division  of  the  Fifth  Nerve 235 

Neui'otomy   of   Third   Division   of   Fifth   Nerve :    Removal   of   Meckel's 

Ganglion  :  Exposure  of  Brachial  Plexus  :  Exposure  of  Spinal  Accessory 

Nerve  ............     237 

The  Third  Division  of  the  Fifth  Nerve 239 

Dissection  of  the  Third  Division  of  the  Fifth  Nerve 242 

Conical  Stump  following  Circular  Amputation  of  the  Thigh,  and  Due  to 

Retraction  of  the  Posterior  and  Internal  Muscles  ....  269 
Stump  of  Right  Arm  after  Amputation  by  two  equal  Lateral  Flaps  :  The 

greater  Retraction  of  the  Inner  Flap  has  drawn  the  Cicatrix  to  the 

Inner  Side  ............     272 

Petit's  Screw  Tourniquet 277 

Weiss's  Modification  of  Signoroni's  Tourniquet.         .....     278 

Transfixion  Amputation  Knife 284 

Amputation  Knife  with  every  Bad  Quality 284 

Amputation  Knife  used  for  Cutting  Flaps  from  without  inwards         .         .     285 
Circular  Amputation  a  la  manchetie    ........     290 

Supporting  Sjdint  adjusted  to  the  Leg  after  Chopart's  Amputation     .         .     309 

Surface  Markings  on  the  Palm  of  the  Hand 318 

A  Finger  Flexed  to  show  the  Joint  Lines  and  the  Epiphyses  .  .  .  319 
Hoi-izontal  Section  through  the  Middle  of  the  Second  l^halanx  .  .  .  .ilO 
ThcM'ideof  Holding  the  Finger  during  the  Disarticulation  of  the  Last 

Plialanx 323 


LIST    OF  ILLUSTRATIONS.  xiii 

PAOB 

Disarticulation  of  the  Phalan,f?es  of  the  Fingers  by  largo  Palmar  Flap — 

Amputation  by  nnequal  Dorso-Palmir  Flaps  .....  82o 
Disarticulation  of  Fingers  at  the  Metacarpo-Phalangeal  Joints : — Disarticu- 
tion  by  Single  External  Flap — Amputation  by  Lateral  Flaps — Dis- 
articulation bj'  Oval  or  Racket  Incision — Modified  Racket  Incision  for 
Index  Finger — Circular  IMcthod,  with  Vertical  Dorsal  Cut — Incision  en 
cronpihre — Interno-Palmar  Flap  Method  for  Little  Finger — Disarticu- 
lation by  Single  Palmar  Flap — Disarticulation  by  Racket  Incision — 
Amputation  of   the  Fingers  with  their  ^Metacarpal  Bones — Circular 

Disarticulation  at  the  AVrist 330 

Disarticulation  of  the  Forefinger  by  Special   Externo-Palmar  Flap — Dis- 
articulation of  the  Middle  Finger  by  Lateral  Flaps — Amputation  of 
the  Thumb  by  unequal  Dorso-Palmar  Flaps — Disarticulation  of  the 
Thumb  by  Obliciue  Palmar  Flap — Disarticulation  of  the  Ring  Finger 
with  its  Metacarpal  Bone  by  Racket  Incision — Same  Operation  upon 
the  Little  Finger — Dubrueil's  Disarticulation  at  the  Wrist  .         .     334 

Disarticulation  of   the   Thumb  with   its  Metacarpal   Bone   by   a   Racket 

Incision       ............     341 

Disarticulation  of  the  Thumb  with  its  Metacarpal  Bone  by  Palmar  Flap — 

Amputation  of  the  Three  Inner  Fingers  with  their  Metacarpal  Bones.     342 
Palmar  Incision  in  the  Circular  Disarticulation  at  the  "VVrist— Incisions  in 

the  Elliptical  Disarticulation  at  the  Wrist 349 

Disarticulation  at  the  Wrist  by  Long  Palmar  Flap     .....     351 

The  Incision  en  8  dc  chifre  .........     361 

Disarticulation  at  the  Elbow-Joint  by  Circular  Method — Disarticulation  at 

the  Elbow-Joint  by  Single  External  Flap 366 

Disarticulation  at  the  Elbow-Joint  by  the  Anterior  Ellipse  Method    .         .     368 
Disarticulation  at  the  Elbow-Joint  by  the  Posterior  Ellipse  Method   .         .     369 
Disarticulation  at  the  Elbow-Joint  by  Anterior  Flap  .....     370 
Circular  (Inclined)  Amputation  of  the  Arm — Amputation  of  the  Arm  by 
Antero-Posterior  Flaps — Amputation  at  the  Shoulder-Joint  by  Deltoid 

Flap 377 

Amputation   of   the   Arm   by  Teale's  Method — Amputation  through  the 

Surgical  Neck  by  Single  External  Flap 378 

Disarticulation  at  the  Shoulder-Joint  by  Racket  Incision    ....     387 

Disarticulation  at  the  Shoulder-Joint 390 

Amputation  at  the  Shoulder-Joint  by  Transfixion       .....     393 

Interscapulo-Thoracic  Amputation     ........     400 

Disarticulation  of  the  Last  Phalanx  of  the  Great  Toe  by  a  large  Plantar 

Flap 405 

Disarticulation  of  the  Second  Phalanx  of  a  Toe  by  the  Racket  or  Oval 
Incision— Disarticulation   of  the  Great  Toe  by  the  Racket  or  Oval 
Incision       ............     407 

Disarticulation  of  the  Great  Toe  by  Internal  Plantar  Flap  .         .         .     408 

Disarticulation  of  the  Great  Toe  by  Internal  Plantar  Flap :  the  Resulting 

Stump 409 

Disarticulation  of  the  Great  Toe  by  Internal  Flap 410 

Disarticulation  of  the  Little  Toe  by  Dorso-Extcrnal  Flap :  the  Resulting 

Stump 412 

Dubrueil's  Operation  for  the  Removal  of  all  the  Toea         ....     414 
Bones  of  Foot  'Line  of  Lisfranc's  Amputation)  .....     419 


xiv  OPERATIVE    SURGERY. 

PAOE 

Transverse  Section  of  the  Foot  at  the  Tarso-Metatarsal  Line  of  Joints       .     i20 

Lisfranc's  Amputation 4-6 

The  CoMjs  rfe  J/ff/nr  in  Lisfi-.inc's  Amputation:  First  Step  .         .         .         .     427 
The  Coup  de  Maitre  in  Lisfranc's  Amputation :  Second  Step        .         .         .     i'H 

Bones  of  the  Foot  (Line  of  Chopart's  Amputation) 431 

Chopart's  Amputation ■^32 

Anatomy  of  the  Stump  after  Chopart's  Amputation 433 

Inner  and  Outer  Sides  of  the  Right  Foot,  to  show  the  Incisions  in  Fara- 

beuf's  Suhastragaloid  Amputation 437 

Subastragaloid  Amputation  of  the  Left  Foot 439 

Disarticulation  of  the  Little  Toe,  together  with  its  Metatarsal  Bone,  by  the 

Oval  or  Racket  Incision — Maurice  Perrin's  Subastragaloid  Amputation     440 
Disarticulation  of  the  Great  Toe,  together  with  its  Metatarsal  Bono,  by 
the  Oval  or  Racket  Incision— Subastragaloid  Amputation  by  Heel 

Flap 441 

Plantar  Incisions 446 

Syme's  Amputation  of  the  Foot 447 

Roux's  Amputation   ......•••••     449 

Farabeufs  Subastragaloid  Amputation— Farabeuf's  Amputation  at  the 
Ankle-joint — Saw-cuts  in  Pirogoff's  Amputation — Saw-cuts  in  Pas- 
quier  and  Le  Fort's  Operation — Saw -cut  in  the  Os  Calcis  in  Tripier's 

Operation 4ol 

Pasquier  and  Le  Fort's  Operation 452 

Tripier's  Operation 4ot 

Osteo-plastic  Resection  of  the  Foot 457 

Aspect  of  Limb  and  Instrument  to  be  worn  after  Osteo-plastic  Resection 

of  the  Foot .458 

Guyon's  Supra-malleolar Amputation— Duval's  Supra-malleolar Amputation    464 

Stump  left  by  Guyon's  Supra-malleolar  Amputation 465 

Stump  left  by  M.  Duval's  Supra-maUeolar  Amputation     ....     468 

Teale's  Amputation  of  the  Leg 470 

Stump  left  after  Teale's  Amputation  of  the  Leg 471 

Modified     Circular    Supra-malleolar    Amputation— Hey's    Amputation- 
Circular  Amputation  at  "  the  Place  of  Election  " — Gritti's  Operation     474 
Mode  of  Dividing  the  Tissues  in  the  Amputation  by  a  Large  Posterior  Flap     476 
Amputation    of    Lower   Part    of    Leg    by    Long    Posterior   Flap— Am- 
putation  at  "the    Place  of    Election"    by    Large    External    Flap 
(Farabeuf's  Operation) — Garden's  Amputation— Lister's  Modification 

of  the  same  .         .         .  ' ■    •         •     480 

Mode  of  Cutting  the  Flap  in  the  Amputation  at  "the  Place  of  Election" 

by  a  Large  External  Flap 481 

Method  of  Sawing  the  Tibia 482 

Method  of  Sawing  the  Bones  of  the  Leg  (2) 482 

Appearance  of  the  Stump  after  the  Amputation  of  the  Leg  at  "  the  I'lace 

of  Election  "  by  a  Large  External  Flap 484 

Stump  resulting  from  Amputation  of  thij  Leg  at  "the  Place  of  Election" 

by  a  Largo  External  Flap 485 

Amputation  at  "  the  Plac«  of  Election  "  by  Lateral  Flaps- Disarticulation 

at  the  Knee  by  Long  Anterior  Flap 490 

titephf-n  Smith's  Disarticulation  at  tlio  Knee— Amputation  of  the  Thigh 

by  Lat(.nil  Flaps 494 


LIST    OF   ILLUSTRATIONS.  xv 

l-AOK 

The  Stump  after  Stephen  Smith's  Amputation  at  the  Knee-joint        .         ,495 
Disarticulation  at  the  Knee  by  the  Elliptical  Method  (Bauden's  Operation) 

— Henry  Lee's  Amputation  of  the  Leg         ......     496 

Farabeuf's  Amputation  through  the  Condyles  of  the  Femur        .         .         .     504 
Circular  Amputation  of  Thigh — Amputation  of  Thigh  by  Equal  Antero- 
posterior   Flails — Disarticulation    at    the    Hip   by   External   Racket 

Incision 512 

Amputation  of  the  Thigh  by  Long  Anterior  and  Short  Posterior  Flaps — 

Disarticulation  at  the  Hip  by  Antero-Posterior  Flaps  .         .         .         .517 

Fumeaux  Jordan's  Amputation  at  the  Hip-Joint        .         ,         .         .         .     535 
Disarticulation  at  the  Hip-Joint  by  an  Anterior  Racket  Incision        .         .     537 
Lisfranc's  Disarticulation  at  the  Hip  by  Internal  and  External  Flaps  .     542 

Section  of  Chisel — Section  of  Osteotome     .......     551 

Macewcn's  Osteotome         ..........     552 

Adams'  Saw       ............     553 

Diagram  to  show  the  Lines  of  the  Chisel  Cuts  in  Cuneiform  Osteotomy  for 

Angular  Deformity  after  Fracture,  etc.        ......     559 

Osteotomy  for  Faulty  Anchylosis  of  the  Hip 563 

Vertical  Section  of  the  Lower  End  of  a  Deformed  Femur,  from  an  Extremt; 

Case  of  Genu  Valgum  .........     565 

Transverse  Section  of  the  Femur  about  the  Level  of  the  Epiphyseal  Line, 

showing  the  Triangular  Outline  of  the  Bone        .....     566 

Macewen's  Operation  for  Genu  Valgum     .......     568 

Ogston's  Operation  for  Genu  Valgum         .......     572 

Diagram  representing  a  Curved    Tibia  with  a  Wedge  removed  for  the 
Purpose  of  Straightening  the  Bone — The  Same  with  the  Bone  straight- 
ened— The  Same  with  the  Bone  simply  divided  and  straightened  .     577 
Cuneiform  Osteotomy  for  Curved  Tibia     .         .         .         .         .         .         .578 

Wiring  of  the  Fragments  of  the  Patella  after  Fracture  .592 

Excision  Knives  (2) 598 

Farabeuf's  Rugines,  Straight  and  Cui-ved  .......     599 

Langenbeck's  Periosteal  Elevator      .         .         .         .         .         .         .         .599 

Blandin's  Director  for  Resections        ........     599 

Farabeuf's  Bone-holding  Forceps       ........     600 

OUier's  Forceps  for  Seizing  Cancellous  or  Friable  Bone    ....     600 

The  Method  of  "Using  the  Rugine 602 

Diagrams  to  Illustrate  the  Subperiosteal  Method  of  Resection    .         .         .     604 
Restoration  of  the   Elbow- joint  after  Subperiosteal  Excision   (Anterior 

View) 606 

Epiphyses  of  the  Thumb  and  Index  Finger        .         .         .         .         .         .610 

Excision  of  Metacarpo-phalangeal  Joint  of  Index — Excision  of  Inter- 
phalangeal  Joint  of  Thumb — E.x.cision  of  Metacarpo-phalangeal 
Joint  of  Thumb — Excision  of  First  Metacarpal  Bone  .         .         .         .612 

Section  through  the  Wrist .615 

The  Sjmovial  Cavities  of  the  Wrist .616 

Lower  End  of  the  Radius  in  a  Subject  aged  Sixteen  .         ....     617 
Lower  End  of  the  Ulna  in  a  Subject  aged  Sixteen      .         .         .         .         .618 

Excision  of  the  Wrist .621 

Excision  of  the  Wrist  (Lister's  Incision)    .......     624 

Lister's  Splint  for  Excision  of  the  Wrist   .         .         .         .         .         .         .625 

OUier's  Wire  Splint  for  Excision  of  the  Wrist 626 


xvi  OPERATIVE    SURGERY. 

PAGE 

Diagrwn  of  Humerus  at  age  of  Fifteen 631 

Upper  End  of  the  Kaclius  in  a  Subject  aged  Fifteen 632 

Upper  End  of  the  Ulna  in  a  Subject  aged  Fifteen      .....  633 

Excision  of  the  Elbow  (Roux's  Incision — Median  Vertical  Incision)    .         .  634 

Excision  of  the  Elbow  :  the  Clearing  of  the  Humerus          ....  635 

Excision  of  the  Elbow :  Sawing  of  the  Humerus 636 

Right  Elbow  after  Excision  by  Dorsal  Incision — Parts   removed  in  the 

Excision      ............  638 

Excision  of  the  Elbow  (Ollier's  Incision — H-shaped  Incision  of  Moreau)    .  640 
Excision    of    the   Elbow :      Lateral    Incision    as  used    in    Excisions    for 

Anchylosis 642 

Mason's  Splint  for  Excision  of  the  Elbow .  644 

Excision  of  the  Shoulder :  Moreau' s  Square  Flap 647 

Excision  of  the  Shoulder  (Supra-acromial  Incision  :  Morel's  Rounded  Flap)  648 

Upper  End  of  the  Humerus  in  a  Subject  aged  Sixteen        ....  649 

Diagram  of  the  Upper  End  of  the  Humerus 650 

Excision  of  the  Shoulder  (Incisions   of  Baudens,  Hueter,  and  Others  — 

Vertical  Incision  of  Langenbeck  and  Others — Morel's  Incision)  .         .  652 

Excision  of  the  Shoulder  :  Posterior  Incision 655 

Excision  of  First  Metatarsal  Bone 665 

Excision  of  First  Metatarsal  Bone :  Flap  21ethod 666 

The  Articulations  of  the  Foot 667 

Excision  of  Astrngalus  (Outer  Incision) — Excision  of  Ankle  (Outer  Incision) 

Excision  of  Os  Calcis 668 

Excision  of  Astragalus  (Inner  Incision) — Excision  of  Ankle  (Inner  Incision)  675 

Vertical  Section  of  Knee-joint  distended  with  Fluid 682 

Epiphyses  of  the  Femur,  Tibia,  and  Fibula 683 

Excision  of  the  Knee  (Transverse  Curved  Incision — Park's  Incision)  .         .  684 

Excision  of  the  Knee  :   the  Sawing  of  the  Lower  End  of  the  Femur  .         .  685 

Excision  of  the  Knee  :  the  Sawing  of  the  Tibia 687 

Excision  of  the  Knee  (U-shaped  flap  :  Ollier's  Subpei-iosteal  Method)         .  691 

Excision  of  the  Hip  :  Langenbeck's  External  Incision         ....  69S 

Excision  of  the  Hip  by  an  External  Incision 701 

Excision  of  the  Hip  by  an  External  Incision 702 

Excision  of  the  Hip :  Liicke's  Anterior  Incision 703 

Excision  of  the  Upper  Jaw  (by  a  Median  Incision — by  Velpeau's  Method) — 

Excision  of  the  Lower  Jaw 721 

Excision  of  the   Upper    Jaw    (by   Langenbeck's   Method — by   Gensoul's 

Method) 724 

Saw  Incisions  in  the  Maxillaj 725 

Aspect  of  Patient  after  Removal  of  the  Upper  Jaw  on  both  Sides        .         .  728 
Nekton's   Operation  for   Nasal   Polj-pus— Chalot's  Operation   for   Nasal 

Pol^^pus 732 

Operations    for    Naso-pharyngeal     Polj-pus    (Langenbeck's    Operation— 

Boeckel's  Operation) 735 

Operations  for  Naso-pharj-ngeal   Polypus   (Ollier's   Operation— Guerin's 

Operation— Langenbeck's  Operation) 737 

Sole  of  the  Foot  in  Talipes  Varus,  to  show  the  Creases  on  the  Skin    .         .  762 


A  MANUAL  OF 

OPERATIVE    SURGERY. 


^aart  I. 
GENERAL    PRINCIPLES. 

CHAPTER   I. 

The    Patient. 

1. — the  condition  of  the  patient  as  11  affects  the 
result  of  an  operation. 

"Never  decide  upon  an  operation,  even  of  a  trivial  kind," 
writes  Sir  James  Paget,  "  wthout  first  examining  the  patient 
as  to  the  risks  of  his  Ufe.  You  should  examine  him  with  at 
least  as  much  care  as  you  would  for  a  life  insurance.  It  is 
surely  at  least  as  important  that  a  man  should  not  die,  or 
suffer  serious  damage,  after  an  operation,  as  that  his  life 
should  be  safely  insured  for  a  few  hundred  pounds." 

In  the  case  of  urgent  operations,  23erformed  for  the  im- 
mediate purpose  of  saving  life — as  in  the  relief  of  a  stran- 
gidated  hernia — few  considerations  weigh  with  the  surgeon 
save  the  one  great  need.  But  in  slight  operations,  in  ampu- 
tations for  deformity,  in  the  removal  of  small,  innocent 
tumours,  in  the  carrying-out  of  plastic  procedures,  and  in 
like  surgical  undertakmgs,  it  is  of  mlinite  importance  that 
every  possible  consideration  be  given  to  all  circumstances 
which  may  affect  the  patient's  well-being. 

No  operation  is  without  risk ;  some  involve  special 
risks ;  some  overwhelming  risks.  It  is  the  surgeon's  duty  to 
estimate  the  proportion  between  the  danger  incurred  by  the 

B 


2  OPERATIVE    SURGERY. 

operation  on  the  one  hand,  and  by  the  disease  if  left  untreated 
on  the  other. 

The  risk  attending  the  removal  of  a  deformed  toe  should 
be  iniinitesimal.  In  properly  selected  cases  it  is  certainly 
trifling.  The  operation,  however,  may  be  followed  by  dangers 
to  life  if  it  be  carried  out  in  the  subject  of  chronic  kidney 
disease. 

If  the  mortaHty  attending  ovariotomy  were  to  be  increased 
threefold  beyond  the  present  percentage,  the  operation  would 
still  be  justifiable,  inasmuch  as  the  death-rate  in  untreated 
cases  is  so  high  as  to  leave  but  little  prospect  of  life. 

On  the  other  hand,  were  the  death-rate  of  hysterectomy 
lower  by  threefold  than  it  is,  it  would  not  sanction  the  per- 
formance of  that  operation  on  account  of  a  small  fibroid 
tumour  which  had  ceased  to  grow,  which  produced  no 
S3'mptoms,  but  which  the  patient,  as  a  wdiim,  was  determined 
to  be  freed  from. 

If  a  patient  w^ishes  to  be  rid  of  a  mere  inconvenience,  or  of 
some  real  or  imagined  blemish,  it  is  exceedingly  important 
that  the  precise  risk  at  which  relief  may  be  obtained  is  clearly 
ascertained. 

Besides  the  risks  to  life,  there  are  possibilities  to  be  con- 
sidered which  may  be  termed  local  risks. 

The  httle  operation  for  the  relief  of  Dupuytren's  contraction 
of  the  palmar  fascia  has  led  to  sloughing  of  the  tissues  of  the 
hand  and  a  cripplmg  of  the  limb  infinitely  more  severe  than 
that  attending  the  original  disease. 

I  have  known  an  operation  for  the  removal  of  a  small 
exostosis  of  the  femur,  which  caused  little  inconvenience,  lead 
to  suppuration  of  the  Icnee  and  a  final  anchylosis  of  the  joint. 

An  operation  for  harelip  carried  out  under  unfavourable 
circumstances  has  left  the  deformity  worse  than  it  Avas  before. 

It  is  of  the  utmost  importance,  therefore,  that  every  care 
should  be  taken  to  arrive  at  a  knowledge  of  the  plwsical 
condition  of  the  individual  upon  whom  even  a  small  operation 
is  to  be  performed.  Every  surgeon  must  have  met  with 
instances  where  he  has  regretted  the  neglect  of  this  funda- 
mental precaution.  I  once  snipped  off  with  the  scissors  a 
small  fibrous  epulis  growing  from  the  gum  of  a  little  boy.  I 
discovered  afterwards — what  I  should  have  known  before — 


THE    CONDITION   OF    THE    PATIENT.  .*{ 

that  the  po.tient  was  the  subject  of  hfemophilia.  The  small 
wound  became  the  seat  of  ahiiost  imcontroUable  hiemorrhasre, 
and  it  Avas  not  imtil  a  fortnight  had  elapsed  that  the  patient 
could  be  said  to  be  out  of  danger.  In  another  case,  I  re- 
moved— at  the  patient's  urgent  request — a  small  sebaceous 
cyst  from  the  scalp  of  a  man  of  fifty.  The  wound  soon  broke 
do"v\Ti,  suppurated  freely,  and  became  the  starting-point  of  a 
low  form  of  erysipelas,  of  which  the  patient  nearly  died.  It 
was  discovered  after  the  operation  that  the  man  was  suffering 
from  diabetes,  a  fact  of  which  he  himself  was  not  aware. 

In  forming  a  proper  estimate  of  the  risks  involved  by 
operations — so  far  as  the  condition  of  the  patient  is  con- 
cerned— many  factors  have  to  be  considered,  and  in  the 
paragraphs  which  follow  the  more  important  are  dealt 
with.* 

Age. — Age  exercises  a  considerable  effect  upon  the  result 
of  operations.  Taking  amputation  as  a  typical  operation, 
it  appears  that  quite  3'oung  children — those  under  the  age 
of  live — do  not  bear  operation  well,  the  mortality  being  as 
high  as  between  the  ages  of  thirty-tive  and  fifty.  The  mort- 
ality is  lowest  between  the  ages  of  five  and  fifteen,  and  these 
years  certainly  give  the  best  results  from  operations  of  almost 
every  kmd.  After  fifteen  the  death-rate  begins  to  steadily 
but  slowly  increase.  The  variation  between  the  whole  period 
fi'om  twenty  to  forty  is  certainly  not  considerable;  but  the 
risk  of  death  after  operation  is  twice  as  great  in  patients 
between  those  ages  as  it  is  in  individuals  under  twenty. 
In  patients  over  forty  the  mortality  is  nearly  three  times 
in  excess  of  the  rate  observed  in  patients  under  twenty.  The 
increase  in  the  risk  of  death  between  fifty  and  seventy  is  very 
rapid. 

In  children  wounds  usually  heal  well ;  the  patient's  organs 
are  healthy  and  vigorous,  and  the  nutritive  activity  of  the 
body  is  in  its  prime.  Children  show  great  recuperative 
power,  and  are  free  from  the  effects  of  that  mental  anxiety 
which  often  acts  so  injuriously  upon  adults.     They  are  able, 

*  Considerable  iise  has  been  made  of  Sir  James  Paget's  classical  Lecture 
upon  the  subject.  The  question  of  the  effect  of  the  operation  itself  is  alone  con- 
sidered. The  special  risks  attending  the  administration  of  an;esthetics  and  the 
circumstances  modifying  those  risks  are  considered  later  (page  78). 


4  OPERATIVE    iSUUGEBY. 

moreover,  to  stand  long  confinement  in  bed,  and  to  endure  a 
tedious  suppuration  with  comparatively  little  ill  effect. 

On  tlie  other  hand,  children  suffer  severely  from  shock 
and  the  effects  of  acute  pain.  Pain,  if  unrelieved,  may  in  a 
few  hours  reduce  a  child  to  a  state  of  collapse.  Mr.  Howard 
Marsh  cites  the  case  of  a  child,  two  years  old,  who  "died 
apjDarently  of  the  pain  and  terror  caused  by  the  repeated 
dressings  of  a  burn  on  the  trunk  and  lower  limbs." 

Shock  is  certainly  the  chief  danger  in  operations  upon 
young  and  healthy  children. 

It  has  been  said  that  children  bear  the  loss  of  blood 
badly.  Mr.  Marsh  has  questioned  the  soundness  of  this 
beUef,  and  Avith  his  view  I  entirely  concur.  Hasmorrhage 
must  be  regarded  relatively  when  comparing  children  with 
adults.  If  the  weight  of  the  body  be  taken  in  conjunction 
with  the  amount  of  blood  lost,  I  think  it  will  be  found  that 
children  bear  haemorrhage  weU,  and,  in  the  case  of  repeated 
bleedings,  often  remarkably  well. 

Operations  should  not  be  performed,  if  possible,  during 
the  tirst  dentition.  Children  are  then  often  restless  and 
excitable,  liable  to  digestive  disturbances  and  to  convulsions, 
and  apt  to  develop  a  high  temperature  under  little  pro- 
vocation. 

The  natural  restlessness  of  children  is  often  an  obstacle  to 
the  perfect  success  of  an  operation,  and  oiJerations  in  the 
region  of  the  pelvis  are  apt  to  be  complicated  by  the  difficulty 
of  keeping  the  child  clean. 

It  is  essential  for  the  good  result  of  a  plastic  operation  that 
the  child  should  be  in  sound  health.  Any  history  of  con- 
vulsions should  be  sought  for ;  and  the  operation  should  be 
postponed  if  the  patient  has  recently  been  exposed  to  the 
risk  of  infection  from  any  of  the  exanthemata. 

The  remarkable  effect  an  operation  now  and  then  appears 
to  have  in  determining  the  appearance  of  scarlet  fever  is  well 
known. 

Of  the  influence  of  old  age  upon  operations,  Sir  James 
Paget  writes: — "Among  the  old  there  are  even  greater  dif- 
ferences than  among  the  younger  in  the  ability  to  recover 
from  operations ;  and  age,  if  reckoned  by  years,  is  not  the 
only  thing  in  them  we  must  estimate.  .  .  .  They  that  are  fat 


THE    CONDITION    OF    THE    PATIENT.  5 

and  bloated,  pale,  with  soft  textures,  flabby,  torpid,  wheezy, 
incapable  of  exercise,  looking  older  than  their  years,  are  very 
bad.  They  that  are  fat,  florid  and  plethoric,  flrm-skinned 
and  with  good  muscular  power,  clear-headed  and  willing  to 
work  like  younger  men,  are  not,  indeed,  good  subjects  for 
operations,  yet  they  are  scarcely  bad.  The  old  people  that 
are  thin  and  dry  and  tough,  clear-voiced  and  bright-eyed, 
with  good  stomachs  and  strong  wills,  muscular  and  active, 
are  not  bad ;  they  bear  all  but  the  largest  operations  very 
welL  But  very  bad  are  they  who,  looking  somewhat  like 
these,  are  feeble  and  soft-skinned,  with  little  pulses,  bad 
appetites,  and  weak  digestive  power,  so  that  they  cannot, 
in  an  emergency,  be  well  nourished. 

"  The  old  are,  much  more  than  others,  liable  to  die  of 
shock,  or  of  mere  exhaustion,  within  a  few  days  after  the 
operation.  They  bear  badly  large  losses  of  blood,  long  ex- 
posure to  cold,  sudden  lowering  of  temperature,  loss  of  food. 
Large  wounds  heal  in  them  lazily.  Their  stomachs,  too,  are 
apt  to  knock-up  with  what  may  seem  to  be  no  more  than 
necessary  food — though,  indeed,  it  often  is  so ;  for  many  old 
people  are  in  less  peril  with  a  scanty  diet  than  Avith  a  full  one. 
Their  convalescence  is  often  prolonged.  .  .  .  There  are 
some  to  whom  convalescence  is  more  dangerous  than  disease. 

"  You  must  choose  for  the  old,  if  you  can,  short  and  gentle 
operations,  and  be  sparing  of  hemorrhage,  and  make  wounds 
that  may  not  lead  to  long  suppurations.  You  must  keep 
them  warm,  and  not  feed  them  beyond  their  real  necessities, 
nor  keep  them  long  recumbent.  In  all  their  convalescence 
you  must  be  constantly  on  the  watch  for  latent  mischief. 
Your  cares  must  be  doubled  Avhen  your  operations  are  on  the 
lower  limbs,  or  the  lower  part  of  the  trunk,  or  on  the  back,  for 
in  operations  on  these  parts  the  risks,  both  local  and  general, 
are  much  greater  than  in  the  parts  above  the  heart.  .  .  . 
Let  me  add  that  of  all  the  conditions  of  disease  or  imperfect 
health  which  influence  the  results  of  operation,  there  is  no 
graver  complication  than  old  age,  unless,  indeed,  it  be  habitual 
intemperance." 

Sex. — Other  things  being  equal,  it  would  appear  fi'om 
statistics  that  Avomen  bear  operations  somewhat  better  than 
men.     This  fact  may  be  explained  by  the  circumstance  that 


6  OPERATIVE    SURGERY. 

they  are  more  tolerant  of  confinement  to  house  and  bed,  lead 
less  active  hves,  and  adapt  themselves  more  easily  to  the 
siirroimdmgs  of  an  operation  ward.  They  are  probably  more 
temperate  and  regular  in  their  hves,  and  owe  not  a  httle  to  a 
certain  natural  determination  and  patience. 

It  is  well  not  to  operate,  unless  compelled,  durmg  menstrua- 
tion. In  perhaps  the  larger  number  of  instances  of  operations 
performed  durmg  this  period  no  ill  effects  are  noticeable ;  in 
the  minority  an  unaccoimtable  rise  of  temperature,  "with  often 
considerable  nervous  and  digestive  disturbances,  are  met  Avith. 
In  more  than  one  instance  I  have  observed  somewhat  severe 
vomiting,  with  undue  abdominal  pain.  The  operation  may 
hasten  by  several  days  the  appearance  of  the  natural  menstrual 
period,  and  it  may  be  then  attended  b}^  unusual  sj^mptoms  of 
excitement  and  of  general  irritation. 

Still  more  desirable  is  it  that  no  operation  should  be  per- 
formed during  j^i'^gnancj^  The  special  risk  incurred  in  such 
a  case  is  that  attending  abortion.  Apart  fi-om  this  risk  there 
is  httle  to  anticipate,  and  wounds  do  well.  Ovariotomy 
and  other  gi-ave  abdominal  operations  have  been  performed 
during  the  various  stages  of  pregnancy  without  inducing 
abortion  and  without  evil  results,  It  appears  to  be  impossible 
to  estimate  the  possibility  of  miscarriage  after  any  surgical 
procedure. 

During  lactation,  also,  operations  should  be  avoided  when 
possible :  the  patient  is  usually  in  comparatively  feeble 
health,  and  certainly  not  in  the  best  condition  for  a  serious 
call  upon  the  nutritive  powers.  Operations  performed  during 
lactation  have,  however,  done  well  enough,  with  the  emphatic 
exception  of  operations  upon  the  breast.  Fatal  htemorrhage 
has  in  more  than  one  recorded  case  followed  an  incision  made 
into  the  active  niamuia. 

The  Robust  and  the  Feeble. — Experience  shows  that  the 
best  subject  for  an  operation  is  not  the  strong,  lusty  man  in 
the  prime  of  life.  He  may  have  mighty  limbs,  and  immense 
strength  and  endurance.  He  may  boast  that  he  has  never 
had  an  ache  or  pain  in  his  life,  and  that  "he  can  stand 
anything."  He  may  lay  claim  to  the  possession  of  what  is 
popularly  known  as  "the  constitution  of  an  ox;"  but  the 
Kursfeon's    knife   is   at   least    one    thin'--    he    can   meet   but 


THE    CONDITION    OF    THE    PATIENT.  7 

indifferently.  He  Avill  probably  not  bear  an  amputation  so  well 
as  some  pale,  puny  individual  of  the  same  age,  who  is  feeble 
and  wasted,  and  who  has  been  laid  up  for  months  with  disease 
of  a  joint. 

The  strong  man  has  his  mode  of  life  suddenlj^  inter- 
rupted. His  blood-vessels  are  full ;  his  viscera  have  adapted 
themselves  to  the  exigencies  of  an  active  life ;  his  tissue- 
changes  are  raj^id  and  extensive,  oxygenation  is  quickl}' 
disposing  of  the  great  refuse  matter  which  is  continually 
accumulating  at  the  very  moment  when  the  tide  is  abruptly 
checked.  The  man  finds  himself  motionless  in  bed ;  every 
circumstance  of  his  hfe  is  changed ;  he  has  had  no  time  to 
adapt  himself  to  his  altered  position,  and  it  is  a  matter  of 
little  wonder  that  the  inflammatory  process  which  has  been 
induced  runs  riot  and  is  not  readily  controlled.  Circum- 
stances are  not  improved  by  his  altered  mental  condition,  by 
the  shock  of  his  accident,  the  horror  of  the  mutilation,  the 
possible  miseries  of  the  future. 

The  subject  of  joint  disease  is,  on  the  other  hand,  ac- 
climatised to  bed-life  ;  his  diet,  his  muscular  changes,  his 
breathmg  powers,  have  all  adjusted  themselves  to  the  mol- 
luscous condition.  His  viscera  are  healthy,  there  is  no 
accumulation  of  debris  to  be  rid  of,  and  possibly  even  con- 
finement is  ceasing  to  be  irksome.  To  such  an  individual 
amj)utation  comes  as  a  rehef.  He  has  been  wearied  of  con- 
tinued pain  and  inefficient  treatment,  and  the  change  that 
amputation  brings  in  his  life  is  agreeable,  and  ojDens  up  the 
prospects  of  a  new  existence.  It  rids  him  of  a  burden  that 
may  have  become  mtolerable.  The  amputation  wound  in 
such  a  man  may  have  healed  soundly  while  the  flaps  in  the 
case  of  the  robuster  patient  are  still  ununited  and  suppu- 
rating. 

The  great  difference  in  the  mortality  of  amputations  for 
injury  and  for  disease  serves  to  emphasise  this  point  (page 
315).  It  must  be  distinctly  understood,  however,  that  these 
differences  are  only  partly  due  to  the  patient's  condition. 
The}"  perhaps  as  largely  depend  upon  the  circumstances  of 
the  amputation,  which  must  of  necessity  be  uncertain  in 
operations  for  injury  where  it  is  difficult  to  ascertain  the  Hmit 
of  the  sound  tissues. 


8  OPERATIVE    SURGERY. 

A  small  operation  upon  a  healthy  man — such  an  one  as 
will  but  little,  if  at  all,  interfere  with  his  daily  mode  of  life — 
may  be  expected  to  do  unusually  well ;  but  if  the  procedure 
be  more  extensive,  and  involve  absolute  confinement,  it  is  as 
well  that  the  patient  should  prepare  himself  by  a  few  days  in 
bed,  and  by  a  modified  diet.  The  preliminary  rest  of  a  week 
in  a  hospital  ward  before  an  operation  may  have  considerable 
effect  upon  the  issues  of  the  procedure  in  the  case  of  a 
labourmg  man  fresh  from  his  work.  In  few,  if  any,  instances 
can  it  be  desirable  to  perform  an  operation  of  expediency  of 
any  magnitude  upon  a  patient  within  a  few  hours  of  admis- 
sion into  the  hospital. 

Obesity  and  Plethora. — The  very  corpulent  are  certainly 
not  good  subjects  for  operation.  In  some  of  them  operations 
do  quite  weU.  These  mil  probably  be  young  persons  in 
whom  the  disposition  to  corpulence  is  hereditary,  who  are  in 
sound  health,  and  take  every  reasonable  means  to  prevent 
increase  of  weight. 

All  obese  individuals  about  or  beyond  middle  life  are,  as  a 
rule,  bad  subjects  for  operations,  and  more  especially  the  men. 
The  excessive  corpulence  may  have  been  induced  by  gluttony 
or  drinking  habits,  or  have  been  encouraged  by  indolence  or 
disease.  These  patients  often  breathe  with  diflicult}^,  and 
cannot  assume  the  entirely  recumbent  position.  They  soon 
become  helpless  ;  their  mere  bulk  renders  it  difficult  for  them 
to  be  moved  in  bed  and  for  dressings  to  be  applied  ;  their 
sldn  is  frequently  unwholesome,  and  they  are  not  readily  kept 
clean. 

The  mteguments  through  which  the  wound  is  made — in 
any  case  involving  a  surface  incision — are  thinned,  anasmic, 
and  flabby.  The  edges  of  the  wound  come  ill  together.  The 
immense  layer  of  subcutaneous  tat  is  indifferently  supplied 
wth  blood,  and  has  probably  been  damaged  during  the 
operation.  Portions  of  this  tissue  have  been  broken  up  and 
isolated  from  a  blood  supply.  Indeed,  in  sponging  these 
wounds  before  the  sutures  are  inserted,  a  quantity  of  such 
isolated  tissue  may  come  away  with  the  sponge.  The  thick- 
ness of  the  parts  involves  much  strain  upon  the  sutures. 
If,  after  the  operation,  the  patient  incline  towards  the  affected 
side,  the  whole  wound  region  becomes  pendulous,  drainage 


THE    CONDITION    OF    THE    PATIENT.  9 

is  difficult,  and  the  application  of  pressure  in  the  dressing 
of  the  incision  is  almost  impossible.  Under  these  circum- 
stances, the  wound  is  very  apt  to  break  doAvn,  sloughing 
is  not  uncommon,  deep-seated  suppuration  is  comparatively 
frequent.  A  low  type  of  inflammation  often  involves  the 
surrounding  skin  ;  the  discharges  become  offensive  and  ill- 
conditioned.  Such  patients  often  die  almost  suddenly ; 
others  become  soon  exhausted,  or  succumb  to  an  inter- 
current disease.  The  most  favourable  make  but  a  tardy 
recovery. 

Plethora,  as  a  simple  condition,  does  not  compromise 
the  success  of  an  operation.  Indeed,  the  "  full-blooded  "  pass 
through  a  surgical  experience  well  enough,  provided  that  the 
plethora  depend  upon  no  diseased  condition.  This  ruddy- 
cheeked,  clear-eyed,  and  firm-limbed  individual  must,  how- 
ever, be  distinguished  from  the  florid  and  bloated  counter- 
feit so  often  represented  by  a  brewer's  drayman  or  a  jovial 
innkeeper. 

Alcoholism. — A  scarcely  worse  subject  for  an  operation 
can  be  found  than  is  provided  by  the  habitual  drunkard. 

The  condition  contra-indicates  any  but  the  most  necessary 
and  urgent  procedures,  such  as  amputation  for  severe  crush, 
herniotomy,  and  the  Hke,  The  mortality  of  these  operations 
among  alcoholics  is,  it  is  needless  to  say,  enormous. 

Many  individuals  who  state  that  they  "do  not  drmk," 
and  who,  although  perhaps  never  drunk,  are  yet  always 
taking  a  little  stimulant  in  the  form  of  "  nips  "  and  an  "  occa- 
sional glass,"  are  often  as  bad  subjects  for  surgical  treatment 
as  are  the  acknowledged  drunkards. 

Of  the  secret  drinker  the  surgeon  has  to  be  indeed  aware. 
In  his  account  of  the  "Calamities  of  Surgery,"  Sir  James 
Paget  mentions  the  case  of  a  "  person  who  was  a  drunkard 
on  the  sly,  and  yet  not  so  much  on  the  sly  but  that  it 
was  well  knoAvn  to  his  more  intimate  friends.  His  habits 
were  not  asked  after,  and  one  of  his  fingers  was  removed 
because  joint  disease  had  spoiled  it.  He  died  m  a  week  or 
ten  days,  with  spreading  cellular  inflammation,  such  as  was 
far  from  unlikely  to  occur  in  an  habitual  drunkard." 

Even  abstinence  from  alcohol  for  a  week  or  two  before 
iin  operation  does  not  seem  to  greatly  modify  the  result. 


10  OPERATIVE    SURGERY. 

An  operation  performed  upon  an  habitual  or  occasional 
drunkard  is  apt  to  be  followed  by  an  outburst  of  delirium 
tremens,  a  complication  that  brings  a  very  greatly  increased 
risk  to  a  patient  already  in  no  little  danger.  It  must  not  be 
assumed  that  an  operation  upon  a  subject  of  alcoholism  must 
of  necessity  turn  out  badly.  The  evil  result  is,  however, 
sufficiently  frequent  to  justify  a  refusal  to  perform  any  but 
urgent  operations,  and  the  occasional  fact  that  grave  opera- 
tion wounds  in  heavy  drinkers  may  heal  kindly  and  well  is 
rather  an  illustration  of  good  fortune  than  of  surgical  success. 

Scrofula  and  Tuberculosis. — On  the  whole,  it  may  be 
said  that  scrofulous  patients  stand  operations  remarkably 
well,  and  this  especially  applies  to  scrofulous  children.  In 
a  large  proportion  of  the  cases,  the  operation  rids  the  patient 
of  a  long-abiding  trouble,  and  a  source  of  persistent  irritation 
and  weakness.  It  is  sometimes  surprising  to  note  how  a 
pale,  Avasted,  cachectic-looking  child,  as  wan  as  a  shadow,  will 
improve  and  gain  in  flesh  and  in  looks  almost  directly  after 
such  an  operation  as  amputation  of  the  leg  for  the  removal 
of  a  wholly  carious  foot.  Some  of  the  best  examples — so  far 
as  speedy  recovery  is  concerned — of  amputation  at  the  hip- 
joint  have  been  met  with  among  strumous  children. 

It  must  be  assumed  that  in  these  and  in  other  cases  there 
is  freedom  fi'om  serious  visceral  disease,  such  as  lardaceous 
degeneration  of  the  liver. 

Operations  upon  the  strumous  are  remarkably  affected  by 
their  surroundings.  The  patient  requires  fresh  air  and  the 
most  favourable  hj'gienic  conditions.  Kesults  may  be  ob- 
tained at  the  seaside  which  can  hardly  be  expected  in  the 
crowded  wards  of  a  city  hospital.  In  any  case — and  especially 
when  operating  in  large  towns — the  after-treatment  of  the 
case  should  be  hastened  as  far  as  is  possible,  and  the  patient 
be  removed  from  bed  and  allowed  to  get  into  fresh  air  as 
soon  as  can  be  managed.  By  means  of  suitable  splints  or 
retentive  apparatus,  this  can  often  be  effected  at  quite  an 
early  period. 

Tlie  operation  wounds  in  these  patients  usually  do  avoU 
at  first — often  remarkably  well.  They  heal  up  in  large  part, 
then  the  healing  process  halts,  pus  is  found  to  be  formed  in 
the   depths  of  the  wound,  a  sinus  is  apt  to  persist,  or  the 


THE    CONDITION   OF    THE   PATIENT.  11 

scar  remains  weak,  or  takes  on  the  character  of  a  strumous 
ulcer.  The  area  of  the  wound  is  occupied  by  a  sodden  con- 
nective tissue,  and  from  the  sinuses  that  exist,  or  from  be- 
neath the  undermined  skin,  a  great  quantity  of  pale,  jelly-like 
granulation  tissue  can  be  scraped. 

Often  enough  this  disappointment,  in  what  seemed  at 
first  to  be  a  speedy  healing  by  first  intention,  is  due  to  an 
imperfect  removal  of  the  original  disease  ;  but  it  is  not  always 
the  case.  A  like  result  may  follow  an  amputation  through 
healthy  parts. 

The  scrofulous  patient  has  little  power  of  sound  plastic 
repair.  Healing  may  be  rapid,  but  it  is  not  always  sub- 
stantial. The  scar  building  in  the  strumous  is  a  httle  com- 
parable to  the  work  of  the  "jerry-builder."  As  Verneuil 
well  says,  operations  upon  the  scrofulous  abound  in  "half 
successes,  incomplete  results,  and  untinished  cures." 

The  success  of  an  operation  upon  these  patients  must  be 
judged  three  months  after  its  performance. 

The  result  can  be  greatly  influenced  by  the  selection  of 
proper  -cases,  by  the  complete  removal  of  ever}'-  atom  of  dis- 
eased tissue  in  the  operation  area,  by  taking  every  step  to 
secure  primary  healing  and  to  avoid  the  formation  of  a  sinus, 
and  by  placing  the  patient  at  as  early  a  period  as  possible  in  a 
fresh  atmosphere. 

In  hospital  practice  in  London,  it  is  most  unwise  to 
undertake  an  operation  of  any  magnitude  upon  a  strumous 
child  if  it  be  known  that  after  the  treatment  the  patient  Avill 
return  to  the  dingy  and  noisome  slum  from  which  he  came. 

Upon  strumous  subjects  of  middle  age,  operations  must  be 
undertaken  more  warily.  The  wounds  in  these  individuals, 
especially  when  they  involve  the  diseased  area,  often  do 
badly,  heal  but  indifferently,  and  are  apt  to  be  associated  with 
inflammatory  processes  of  the  lowest  type. 

I  have  pointed  out  elsewhere  ("Scrofula  and  its  Gland 
Diseases ")  that  two  independent  scrofulous  manifestations 
seldom  exist  in  the  same  patient  at  the  same  time,  and  that 
upon  the  cure  of  one  strumous  affection  another  of  a  per- 
fectly different  character  may  appear.  This  sequence  has 
been  observed  as  well  after  cure  by  operation  as  after  cure 
by  natural  means ;  and  it  is  possible  that  in  some  cases  the 


12  OPERATIVE    8UBGEBY. 

impairment  of  the  health  incident  to  the  surgical  treatment 
has  been  favourable  to  the  development  of  the  fresh  mani- 
festation. 

The  occurrence,  however,  is  not  common  enough,  nor  is 
the  evil  exercised  by  the  operation  sufficiently  demonstrated, 
to  allow  these  occasional  calamities  to  influence  treatment, 
except  in  so  far  as  to  emphasise  the  fact  that  a  condition  of 
feeble  health  is  favourable  to  the  development  of  the  tuber- 
cular process. 

On  the  question  of  operations  upon  the  subjects  of 
2Dhthisis,  Su'  James  Paget  writes  as  follows  : — "  The  fever  and 
other  accidents  that  may  follow  an  operation  may  do  special 
harm  to  a  tuberculous  patient.  .  .  .  The  fear  of  such  a 
calamity  should  dissuade  you  from  all  operations  of  mere 
convenience,  and  from  all  measures  of  what  may  be  called 
decorative  surgery,  in  phthisical  people ;  but  it  should  not 
always  dissuade  you  from  operations  that  will  cure  diseases 
from  which  they  suffer  much,  and  by  wdiich  their  lives  are 
wasted,  as  they  are  by  fistula  and  diseases  of  bones  and 
joints.  In  these  and  the  like  cases,  the  main  question  is, 
whether  the  local  disease — say,  a  diseased  joint — is  weighing 
on  the  patient  so  heavily,  or  aggravating  his  phthisis  and 
shortening  his  Hfe  so  much,  as  to  justify  an  operation 
attended  with  more  than  the  average  risk  of  Ufa  and  health. 

"  In  all  cases  of  acute  or  progressive  phthisis,  great  risk  is 
incurred  by  almost  every  operation.  The  risks  of  the  ex- 
citement of  many  days  of  feverish  disturbance,  and  of  loss 
of  food,  and  of  pain,  and  all  such  consequences  of  operations, 
are  much  above  the  average ;  to  say  nothing  of  the  special 
chances  of  exciting  some  pneumonia.  I  cannot  doubt  that 
I  have  seen  patients  whose  acute  phthisis  has  become 
more  acute,  and  others  in  whom  the  early  stages  of 
phthisis  were  accelerated  by  the  consequences  of  operations. 
Therefore,  I  should  follow  the  rule  of  never  performing  any 
con.siderable  operation,  if  I  could  help  it,  on  any  person  whose 
phthisis  is  in  quick  progi'ess. 

"  The  case  is  very  different  with  chronic  or  suspended 
phthisis.  In  these  it  is  often  advisable  to  incur  the  somewhat 
increased  risk  of  even  a  large  operation,  in  order  to  free  the 
patient  from  the  distress  and  wasting  of  a  considerable  local 


THE    CONDITION    OF    THE    PATIENT.  13 

disease,  such  as  that  of  a  joint;  and  I  should  be  disposed  to 
say  that  it  is  always  advisable  to  cure,  if  you  can,  a  small 
disease,  such  as  a  fistula.  I  say  if  you  can,  for  you  will  often 
be  disappointed.  In  the  tuberculous,  as  in  the  strumous, 
your  wounds  will  remain  for  weeks  unhealed,  and  perha])s 
be  unsoundly  healed  at  last.  Still,  as  to  the  mere  question 
of  operating,  I  have  seen  so  many  advantages  accrue  to 
patients  with  chronic  phthisis  from  the  removal  of  limbs 
with  joint  disease,  that  I  am  disposed  to  speak  strongly  as 
to  the  general  propriety  of  whatever  operations  they  may 
reasonably  require." 

Syphilis. — In  the  great  majority  of  cases,  syphilis  does 
not  injuriously  affect  the  course  of  an  operation,  and  is  no 
bar  to  such  a  measure.  If  the  patient  be  rendered  cachectic, 
or  be  the  subject  of  visceral  disease,  he  is  placed  in  the  same 
unfavourable  category  with  those  w4io  are  similarly  affected 
from  other  causes.  Wounds  made  during  the  progress  of 
secondary  syphilis  more  often  heal  well  than  show  any  evil 
tendency ;  occasionally  they  become  the  seat  of  a  transient 
syphilitic  manifestation,  and  heal  indifferently,  or  break  down 
after  a  speedy  closure.  Such  an  event  may  occur  without 
the  appearance  of  any  distinct  syphilitic  change  in  the  part. 
The  same  may  be  said  of  operations  performed  late  in 
syphiHs,  or  many  years  after  its  occurrence.  They  usually 
do  well.  In  the  minority  of  the  cases,  however,  primary 
heahng  is  not  secured,  or  the  wound  heals,  and  breaks  doAvn 
again,  or  remams  open,  and  becomes  the  seat  of  a  dull,  persist- 
ing suppuration,  or  of  an  ulcer  possessed  of  specific  characters. 
This,  perhaps,  more  often  happens  when  the  incision  involves 
tissues  which  have  been  previously  damaged  by  syphilitic 
disease.  Thus  it  comes  to  pass  that  plastic  o]3erations  not  in- 
frequently fail  in  syphilitic  persons,  especially  when  performed 
for  the  relief  of  deformities  produced  by  some  destructive 
manifestation  of  the  disease.  Such  ojierations  should  not  be 
Hghtly  undertaken  nor  carried  out  until  every  means,  both 
by  general  and  specific  treatment,  has  been  taken  to  place 
the  patient  in  the  best  condition  of  health. 

Rheumatism  and  Gout  have  practically  no  effect  upon  the 
immediate  future  of  an  operation.  The  wound  heals  kindly 
and  welL     It  is  unnecessary  to  say  that  an  operation  should. 


14  OPERATIVE  SUEGERY. 

if  possible,  not  be  performed  during  an  outbreak  of  either  of 
these  conditions.  It  must  be  remembered,  also,  that  any  of 
the  sequelte  of  gout  or  rheumatism  may  comphcate  the  issues 
of  an  operation.  Such  are  the  cardiac  changes  so  often 
attendant  upon  the  former  disease,  and  the  degenerations  of 
the  kidneys  and  other  viscera  which  are  apt  in  course  of 
time  to  follow  upon  the  latter. 

An  operation  not  infrequently  determines  an  attack  of 
gout,  but  such  attack  usually  has  no  noteworthy  effect  upon 
the  progTess  of  the  wound.  Verneuil  remarks  that  gout 
sometimes  manifests  itself  at  the  site  of  injury  by  fluxions, 
with  acute  pains,  which  simulate  frank  inflammation,  and 
which,  although  of  only  a  temporary  character,  may  suspend 
or  retard  the  healing  process. 

Cancer  does  not  render  a  patient  a  bad  subject  for  opera- 
tion. The  result  of  the  operation  may  be  moditied  by  other 
conditions,  such  as  the  age  and  temperament  of  the  subject, 
and  the  presence  of  visceral  disease.  Cancer,  as  such,  appears 
to  exercise  no  effect  upon  the  heahng  process.  Indeed,  opera- 
tions for  the  removal  of  maUgnant  growths  in  old  and  broken- 
down  individuals  often  do  remarkably  well. 

Anaemia,  especially  when  due  to  loss  of  blood,  has  no 
special  effect  upon  a  surgical  wound.  The  healing  may  be 
slow  ;  the  patient  is  perhaps  rendered  unduly  liable  to  the 
more  serious  comphcations  which  follow  upon  wounds,  and 
has  little  poAver  to  meet  such  misfortunes.  It  is  most  import- 
ant that  before  an  operation  of  expediency  be  performed,  the 
anaemic  condition  should  be  dealt  with  by  proper  treat- 
ment. 

Leucocythsemia  has  a  most  disastrous  influence  upon 
operation  wounds.  Splenectomy,  although  performed  many 
times  in  the  subjects  of  leucocythaemia,  has  been  followed  by 
one  uniform  result — all  the  patients  have  died. 

Serious,  if  not  fatal,  results  have  followed  in  less  grave 
procedures,  and  in  the  leucocythcemic  person  even  a  trivial 
operation  is  dangerous.  They  stand  in  great  peril  of  haemor- 
rhage, and  become  the  ready  subjects  of  low  forms  of  inflam- 
mation, of  celluHtis,  and  alhed  conditions. 

Haemophilia  forbids  a  surgical  operation  of  any  but  the 
most  pressing  Ivind.     If  the  operation  proposed  be  urgent  and 


THE    CONDITION   OF    THE    PATIENT.  15 

required  to  save  life,  and  if  the  risk  involved  by  the  disease 
or  injury  be  clearly  greater  than  that  Avhich  may  attend  a 
wound  in  a  "  bleeder,"  it  is  obvious  that  the  operation  should 
bo  carried  out.  Thus,  an  incision  for  the  relief  of  stran- 
gulated hernia,  after  every  form  of  treatment  has  been  tried, 
is  justifiable.  The  subjects  of  hemophilia  do  not  always 
bleed  desperately  after  a  wound ;  perhaps  the  most  certain 
haemorrhage  will  occur  after  an  operation  upon  the  mouth. 
Still,  a  member  of  a  "  bleeder  family,"  who  has  nearly  bled  to 
death  from  a  slight  accidental  cut  of  the  lip,  may  undergo  an 
amputation  of  the  foot  with  no  more  than  the  usual  loss  of 
blood. 

Scurvy  must  stand,  so  far  as  operations  are  concerned,  in 
the  same  position  as  haemophilia.  Apart  from  the  risk  of 
haemorrhage  which  follows  an  operation  performed  during  an 
attack  of  scurvy,  there  are  the  further  dangers  attending  a 
wound  which  does  not  heal,  which  ulcerates  and  leads  to 
interminable  suppuration. 

Malaria. — The  complex  associations  of  malaria  and  injury 
are  very  clearly  dealt  with  by  Yerneuil  in  the  following  pas- 
sages:— "^lalaria  may  give  rise,  at  the  site  of  injury,  to  various 
comj)lications,  such  as  haemorrhage,  neuralgia,  erysipelas,  and 
spasms,  complications  which  assume  an  intermittent  type, 
and  which  yield  to  the  employment  of  quinine. 

"  The  influence  of  the  poison  is,  however,  not  always 
shown  by  periodical  disturbances.  Certain  wounds  may  as- 
sume a  bad  appearance,  or,  at  least,  remain  stationary,  until, 
the  cause  being  suspected,  quinine,  which  acts  like  a  charm, 
is  administered.  It  is  especially  in  cases  of  malarial  cachexia 
that  are  observed  that  slowness  and  insufficiency  of  reiDair, 
which  end  in  serious  diffuse  inflammations,  or  even  in  gan- 
grene, and  which  are  not  always  subdued  by  antiperiodic 
remedies. 

"  The  operation  may  occur  under  one  of  the  following  cir- 
cumstances : — 

"1.  In  a  patient  actually  aft'ected  by  intermittent  fever. 
In  this  case  the  wound,  especially  if  it  be  followed  by  hemor- 
rhage, rapidly  and  markedly  aggravates  the  disease. 

"2.  In  a  patient  who  has  j)i'eviously  been  the  subject 
of  ague,  but  who  appears  to  have  entirely  recovered.     The 


16  OPERATIVE    SURGERY. 

■wound,  even  when  slight,  may  induce  a  fresh  onset  of  ague ; 
although  the  recovery  from  the  last  attack  of  fever  was  five, 
ten,  fifteen,  or  even  more  years  ago.  On  the  other  hand,  the 
wound  itseK  may  become  the  seat  of  some  local  intermittent 
complications,  the  patient  being  free  from  the  usual  mani- 
festations of  the  disease. 

"  3.  In  a  patient  who  has  never  had  intermittent  fever, 
who  is  hving  in  a  healthy  country,  but  who  has  formerly 
resided  in  a  malarial  district.  The  wound  in  such  cases  may 
apparently  give  rise  to  intermittent  fever  or  to  intermittent 
comphcations.  It  is  clear  that  the  injury,  not  being  able 
of  itself  to  produce  a  true  intoxication,  has  merely  provoked 
the  explosion  of  a  hitherto  latent  disease.  These  latter  cases 
are  not  veiy  rare,  and  are  especially  observed  in  large  cities 
and  in  the  healthiest  regions." 

Acute  Diseases,  Erysipelas,  and  Inflammation. — It  is 
needless  to  say  that  no  operation,  except  such  as  is  so  urgent 
as  to  be  necessary  to  save  life,  should  be  performed  during  the 
progress  of  any  acute  disease,  such  as  pneumonia,  an  eruptive 
fever,  and  the  hke. 

The  same  may  be  said  of  erysipelas.  Incisions  have  to 
be  made  in  the  course  of  that  disease  to  reheve  tension  and 
to  evacuate  pus,  but  they  cannot  rank  as  operative  measures. 
If  an  amputation  is  rendered  necessary  in  a  subject  of  ery- 
sipelas, the  less  danger  would  attend  the  postponement  of  the 
operation  until  the  acute  period  of  the  fever  had  j)assed. 

It  is  most  important  to  avoid,  Avhcn  possible,  any  opera- 
tion upon  inflamed  parts.  This  aj)plies  as  well  to  so  small 
an  operation  as  the  removal  of  a  pile  as  to  the  excision  of  a 
large  tumour.  With  operations  in  the  present  sense  are  not 
classed  such  surgical  measures  as  are  employed  for  the 
rehef  of  inflammation. 

Sir  James  Paget  gives  a  striking  example  of  departure 
from  this  rule.  "  A  man  came  to  me,"  he  writes,  "  in 
the  out-patient's  room,  with  a  cyst  on  the  front  of  his  ab- 
domen, acutely  mflamcd.  I  removed  it  at  once.  Three  or 
four  days  afterwards  he  was  admitted  with  inflammation  ol 
the  ceUular  tissue  and  infiltration  of  putrid  matter  under  the 
skin  ;  and  that  was  followed  by  phlebitis,  and  that  by  pytemia, 
and  that  by  death." 


THE    CONDITION    OF    THE    PATIENT.  17 

iit  may  be  here  remarked,  also,  that  a  good  and  fine 
cic^-trix  cannot  be  expected  if  the  margins  of  the  wound  are 
formed  of  tissues  which  were  inflamed  when  the  incision  was 
made.  This  is  well  illustrated  by  operations  upon  the  neck 
for  gland  disease,  in  which  it  is  a  point  that  the  resulting  scar 
should  be  as  insignificant  as  possible. 

Affections  of  the  Nervous  System. — The  mental  state  of  a 
healthy  patient,  as  expressed  by  the  terms  "  nervous,"  "  neur- 
otic," "  excitable,"  "  apathetic,"  has  little  definite  effect  upon 
the  result  of  an  operation.  The  very  nervous  individual,  who 
ajjproaches  the  operation  with  bated  breath,  who  discusses  it 
with  a  fluttering  vivacity,  and  is  haunted  by  exaggerated  fore- 
bodings, usually  does  well  enough.  After  the  operation  is 
over,  her  imagination  probably  enters  upon  a  new  field ;  she 
conceives  and  prophesies  a  speedy  recovery,  and  often  as- 
sumes the  role  of  the  unusually  hopeful  and  courageous 
patient. 

The  least  favourable  frame  of  mind  is  that  marked 
by  gloom  and  utter  apathy,  and  by  a  morbid,  stoical  indif- 
ference, difiiculf  to  dispose  of.  It  is  illustrated  by  the  dull- 
faced  woman,  whose  conversation  smacks  of  "  Meditations 
among  the  Tombs  ; "  and  by  the  sullen  man,  who  meets  a 
cheery  account  of  the  hopeful  prospects  of  his  operation  by 
the  remark  that  "  he  is  ready  to  go." 

Possibly  the  most  favourable  nerve  conditions  are  met 
with  among  healthy  young  men,  who  sleep  well,  take  whatever 
happens  as  a  matter  of  course,  make  few  inquiries,  and  meet 
all  circumstances  in  the  spirit  of  Mark  Tapley. 

Operations  upon  hysterical  or  epileptic  patients  are  apt  to 
be  complicated  in  their  after-treatment  by  outbreaks  of  the 
nerve  affection.  While  attacks  of  both  hysteria  and  epilepsy 
are  clearly  often  induced  by  an  operation,  on  the  other  hand 
a  precisely  opposite  effect  may  follow  the  surgical  measure. 

The  insane  bear  operations  unusually  well,  provided  that 
certain  conditions  are  present.  They  must  be  in  sound 
health,  and  amenable  to  treatment,  and  of  cleanly  habits 
The  regular  life  of  an  asylum  is  conducive  to  a  state  of 
health  very  well  adapted  to  meet  the  strain  of  an  operation ; 
and  the  absence  of  mental  anxiety  in  the  patient  is  another 
favourable  feature.     In  many  subjects  of  chronic  mania,  of 


18  OPERATIVE    SURGERY. 

melancholia,  and  of  dementia,  the  general  health  is  quite 
broken  down,  and,  as  a  consequence,  they  become  unfit  sub- 
jects for  any  operative  treatment.  In  those  of  the  insane,  also, 
who  are  violent,  restless,  mischievous,  or  of  very  dirty  habits, 
the  success  of  the  operation  may  be  so  far  frustrated  by  the 
patient  that  its  performance  becomes  a  matter  of  question. 

In  not  a  few  instances,  insanity  appears  to  have  been 
induced  by  operation.  The  patients  are  mostly  women,  and 
the  operation,  for  the  most  part,  one  concerning  the  breast 
or  pelvic  organs.  The  occurrence  of  this  unfortunate  circum- 
stance is  neither  frequent  enough  nor  sufficiently  well  defined 
to  mfluence  a  surgeon  in  the  performance  of  a  necessary 
operation. 

It  is  needless  to  point  out  that  operations  performed  upon 
paralj'^sed  limbs  or  upon  the  loAver  extremities  of  the  subjects 
of  locomotor  ataxia  can  scarcely  be  expected  to  turn  out  well. 
The  gloomiest  forebodings  are  often  not  realised,  but  on  such 
individuals  operati'ons  should  not  be  performed  except  on 
compulsion. 

Diabetes  offers  an  almost  positive  bar  to  any  kind  of 
operation.  A  wound  in  a  diabetic  subject  will  probably  not 
heal,  while  the  tissues  appear  to  offer  the  most  favourable 
soil  for  the  development  of  putrefactive  bacteria.  The  wound 
gapes,  becomes  foul,  suppurates,  and  sloughs.  Gangrene  very 
readily  follows  an  injury  in  diabetics,  and  they  show  a  ter- 
rible proneness  to  a  low  form  of  erysipelas  and  of  spreading 
cellulitis.  Diabetic  gangrene  of  a  limb  is  scarcely  Avithin  the 
scope  of  surgical  measures.  An  amj)utation  in  such  a  con- 
dition is  almost  invariably  fatal. 

Even  when  the  diabetes  has  been  actively  treated,  and  the 
patient's  condition  has  much  improved,  an  operation  is  still 
almost  as  unpromising.  After  the  injury  the  amount  of 
sugar  in  the  urine  increases  again,  and  the  result  of  months  of 
careful  treatment  is  rendered  of  little  avail. 

Visceral  Disease. — 1.  Heart  Disease  and  Atheroma. — In 
the  matter  of  heart  affections,  it  may  be  said  that  the  patient 
whose  heart  is  feeble,  or  fatty,  or  embarrassed  by  valvular 
disease,  is  exposed  to  extraordinary  risk  from  the  shock  of  an 
operation,  but  apart  from  this,  heart  disease,  if  it  has  induced 
no  -vvidespreading  tissue  change,  appears  to  add  little  to  the 


THE    COyniTION    OF    THE    PATIENT.  AS 

(lansrer  of  the  iindertaldntr.  On  the  other  hand,  as  Verneuil 
points  out,  valvular  lesions  and  degeneration  of  the  muscular 
tissue  of  the  heart  may,  by  changing  the  conditions  of  the 
entire  circulation,  modify  the  coniposition  of  the  blood,  cause 
impairment  of  the  viscera,  alter  the  tissues,  and  bring  about 
a  condition  very  unfavourable  to  the  healing  process.  Such 
patients  show  a  disposition  to  passive  haemorrhages — ditKcult 
to  check,  together  with  oedema  of  the  wounded  region — to 
patches  of  erythema,  to  erysipelas,  and  even  to  gangrene. 
There  is  a  local  atony  Avhich  indefinitely  delays  healing  and 
converts  the  wound  into  an  ulcer. 

Operations  are  often  performed  upon  limbs  the  arteries  of 
which  are  affected  by  atheroma.  It  is  surprising  how  well 
ligatures  maintain  a  hold  upon  such  vessels,  and  how  well 
they  remain  closed.  The  risk  that  would  appear  to  be  most 
pressing,  that  of  secondary  haemorrhage,  is  in  actual  practice 
seldom  encountered.  That  wounds  in  such  patients  are  more 
liable  to  secondary  bleedings  than  are  wounds  involving  parts 
supphed  by  normal  arteries  is  true,  but  the  occurrence  is  not 
frequent.  The  real  risks  in  these  cases  are  from  gangrene, 
from  sloughing  of  the  flaps  of  an  amputation,  or  the  breaking 
down  of  the  simplest  incision,  and  from  diffuse  inflammations 
of  a  low  type. 

2.  Lung  Disease. — The  relation  of  phthisis  to  the  results 
of  an  operation  has  been  already  considered.  Any  chronic 
lung  affection,  such  as  chronic  bronchitis,  usually  indicates 
impaired  health,  and  offers  difficulties  in  the  after-treatment 
on  account  of  the  embarrassed  breathing,  the  disturbance 
of  parts  produced  by  coughing,  and  the  imperfect  oxj'genation 
of  the  blood.  Operations  on  such  individuals  can  hardly  be 
expected  to  follow  a  quite  even  course. 

3.  Afections  of  the  Alimentary  Canal.  — In  the  matter 
of  affections  of  the  alimentary  canal  there  is  little  to  be  said. 
The  effect  that  any  disease  of  the  stomach  or  intestines  may 
have  upon  an  operation  is  to  be  measured  by  the  effect  it 
has  upon  the  general  health.  The  subject  of  chronic 
dysj)epsia  can  hardly  be  well  nourished,  and  the  subject 
of  habitual  constipation  is  burdened  Avith  a  trouble  which 
an  operation  serves  to  complicate.  It  is  unnecessary  to  state 
that  an  operation  of  any  kind  should  be  avoided  during  the 


20  OPJEIUTIVE    SUB.GEBY. 

course  of  diarrhoea  or  dysentery,  and  should  not  be  undertaken 
until  the  patient  has  Avell  recovered  from  the  trouble. 

4.  Diseases  of  the  Liver. — Affections  of  the  liver  have  a 
very  injurious  influence  upon  operations ;  an  influence  which 
is  peculiar  and  pronounced,  and  a  frequent  cause  of  death  in 
surgical  wards. 

Even  the  slighter  forms  of  hepatic  trouble  serve  to 
compromise  the  future  of  an  operation.  "You  should  be 
cautious,"  writes  Sir  James  Paget,  "  in  operations  upon  those 
whose  bihary  secretions  are  habitually  unliealthy ;  those  who 
have  been  often  jaundiced ;  or  those  who  bear  that  sallow, 
dusky  complexion,  with  dry  skin,  and  dilated  small  blood- 
vessels of  the  face,  and  sallow,  blood-shot  conjunctiva,  which 
commonly  tells  of  what  is  supposed  to  be  an  '  inactive  Hver.' 
Many  of  this  last  class  are  not  temj^erate ;  many  are  sedentary 
and  indolent ;  many  suffer  habitually  from  haemorrhoids ; 
probably  all  have  some  abdominal  plethora;  probably,  in  all, 
their  digestive  organs  act  as  ill  as  their  skins  do.  But,  what- 
ever we  may  guess  to  be  the  special  defect  of  these  organs, 
you  need  not  doubt  that  operations  upon  those  who  have 
them  are  attended  with  more  than  the  average  risk ;  and  that 
when  you  are  obliged  to  operate,  you  must  do  so  with  more 
than  ordinary  care  and  caution." 

The  more  defined  diseases  of  the  liver  have  a  definite 
ill  effect  upon  surgical  wounds.  These  are  cirrhosis  of  the 
liver  and  the  conditions  of  fatty  or  amyloid  degeneration. 
Advanced  forms  of  these  affections  offer  an  almost  absolute 
bar  to  operation.  Operations  performed  in  the  earlier  stages 
of  the  disease  will  certainly  be  injuriously  afiected.  The  sub- 
ject of  cirrhosis  is  probably  a  drunkard ;  the  subject  of 
amyloid  degeneration,  the  victim  of  long-continued  suppura- 
tion. 

The  risks  these  patients  run  are  numerous :  some  succumb 
to  shock,  others  die  of  exhaustion.  In  all  there  is  a 
great  risk  of  secondary  haemorrhage,  and  a  probability  that 
the  wound  will  not  heal,  but  that  it  will  slough  and  sup- 
purate, and  become  the  seat  of  spreading  inflammation  of  a 
low  type.  Pya3niia  is,  or  was,  undul}-  common  in  these 
patients. 

Ko  question  is  more  difficult  to  decide  than  that  which 


THE    CONDITION    OF    THE    PATIENT.  21 

concerns  the  period  in  the  progress  of  lardaceous  disease 
of  the  liver  beyond  which  it  is  practically  unjustifiable  to 
operate. 

In  the  advanced  stages  of  the  disease  a  serious  operation  is 
certainly  not  justifiable.  In  tb  3  earlier  periods,  an  operation, 
such  as  an  amputation,  may  be  performed  with  ultimate 
admirable  success,  for  it  not  only  rids  the  patient  of  his 
trouble — probably  a  suppurating  joint,  with  adjacent  necrosed 
bone — but  it  removes  the  cause  of  the  visceral  complica- 
tion. 

5.  Kidney  Disease. — It  may  be  safely  said  that  the  results 
of  operations  are  more  powerfully  mfluenced  by  diseases  of  the 
kidneys  than  by  a  corresponding  disease  of  any  other  organ. 
An  operation  upon  the  subject  of  Bright's  disease,  or  of  sur 
gical  kidney,  is  a  desperate  matter.  A  patient  may  look  fairly 
healthy,  may  appear  well  nourished,  may  be  temperate  and 
living  a  most  regular  life,  and  the  operation  may  be  but  a 
trifling  one,  yet  the  comphcation  of  albuminuria  renders  the 
surgical  procedure  one  of  the  most  serious  and  the  most 
hazardous.  Many  an  elderly  man  has  died  almost  sud- 
denly from  the  effects  of  rough  catheterisation,  and  it  has 
been  found  after  death  that  he  was  the  subject  of  an  unsus- 
pected pyehtis. 

Quite  slight  operations,  of  no  urgency,  such  as  that  for 
the  relief  of  Dupuytren's  contraction  of  the  palmar  fascia, 
have  placed  the  subjects  of  Bright's  disease  in  great  danger 
of  death. 

In  no  case  should  an  operation  on  an  adult  be  under- 
taken without  a  prehminary  examination  of  the  urine. 

Before  performing  an  abdominal  operation,  it  should  be  a 
matter  of  routine  that  the  urine  be  examined  daily  for  not 
less  than  one  week.  Almost  every  surgeon  must  have  met 
•with  instances  in  which  the  neglect  of  this  precaution  has 
led  to  calamitous  results. 

It  is  impossible  to  define  the  particular  power  for  evil 
each  individual  affection  of  the  kidney  has  upon  a  surgeon's 
work.  It  is  sufficient  to  know  that  the  existence  of  pus  or 
albumen  in  the  urine  places  a  patient  "svithin  the  very  nar- 
rowest sphere  of  operative  possibilities.  It  is  true  that  in 
some  instances — as  in  a  form  of  albuminuria  met  with  in 


22  UPERATIVE    SURGERY. 

connection  with  large  abdominal  tumours — the  existence  of 
!,he  albumen  is  no  bar  to  an  operation ;  it  is  true,  also,  that 
patients  with  Bright's  disease  have  now  and  then  recovered 
admirably  from  large  operations.  The  fact  remains  that 
organic  disease  of  the  kidnej^  is  one  of  the  most  serious 
comphcations  with  which  the  operator  can  be  concerned. 

The  subjects  of  kidney  disease  exhibit  nearly  the  same 
evil  tendencies  after  operation  as  have  been  alluded  to  in 
dealing  with  hepatic  troubles.  They  are  exposed  to  the 
additional  risk  of  death  fi'om  suppression  of  urine  and  ursemia. 
Such  patients  often  die  of  exhaustion  many  days,  or  even 
a  week  or  more,  after  the  operation.  They  are  especially 
prone  to  all  the  evils  incident  to  wounds.  Primary  heahug 
oan  never  be  depended  upon. 

A  plastic  operation  is  unjustifiable  in  a  subject  of  kidney 
disease ;  the  operation  wound  is  hable  to  break  do^vn,  to 
suppurate,  and  be  the  seat  of  secondary  hsemorrhage,  of 
erysipelas,  of  a  foul  cellulitis,  and  of  gangTcne.  When 
pyemia  was  common  in  hospital  wards,  the  subject  of 
kidney  disease  became  its  readiest  victim.  Surgeons  have 
learnt  how  to  ward  off  pyaemia,  but  they  have  yet  to  learn 
how  to  meet  the  terrible  complication  of  Bright's  disease. 

2. — THE    PREPARATION    OF    THE    PATIENT. 

The  Period  before  the  Operation. — It  will  be  evident,  from 
what  has  been  aheady  Avritten,  that  the  most  thorough 
examination  possible  of  the  patient  should  be  made  before 
an  operation  is  undertaken. 

To  carry  this  out,  it  is  well  that  the  individual  should  be 
under  observation  for  some  little  time  before  he  ap[)ears  in 
the  operating  room. 

In  the  case  of  those  who  have  been  long  confined  to  bed, 
it  is  obvious  that  the  sooner  they  are  relieved  the  better. 

On  the  other  hand,  in  the  matter  of  operations  of  ex- 
pediency upon  patients  who  may  be  termed  healthy,  it  is 
well  that  they  should  pass  through  a  period  of  rest  before 
the  operation  is  performed.  Operations  hurriedly  undertaken 
are  often  perilous,  and  are  not  infrequently  regretted.  It  has 
been   already   pointed   out    (page  0)   that   the   condition   cf 


THE    PBEFABATION   OF    THE    PATIENT.  23 

active,  robust  health  is  not  the   best  adapted    to  meet  the 
circumstances  of  surgery. 

In  hospital  practice  it  is  never  wise  to  operate  upon  a 
man  who  comes  straight  to  the  wards  from  some  active 
out-door  work,  who  is  robust,  and  has  been  hving  heartil}', 
and  who  has  still  the  vigorous  throb  of  exercise  in  his 
blood  and  in  his  limbs.  To  perform  upon  such  a  patient 
such  an  operation  as  that  involved  in  the  radical  cure  of 
hernia,  is  to  expose  him  to  needless  and  reckless  risk.  The 
practice  is  frequent,  for  the  operation  has  been  previously 
arranged,  and  the  man  does  not  want  to  lose  even  a  few 
hours'  work. 

Such  a  patient  is  placed  in  an  infinitely  better  condition 
by  a  few  days'  rest  in  a  hospital  ward.  He  here  becomes 
accustomed  to  his  surroundings ;  he  has  time  to  be  rid  of 
the  refuse  matter  in  his  tissues,  which  can  no  longer  be 
cast  oif  by  muscular  exertion  ;  his  hearty  appetite  is  enabled 
to  adapt  itself  to  his  present  requirements ;  the  excreta  can 
be  dealt  with ;  and  time  is  allowed  (and  it  is  needed  in  some 
hospital  patients)  to  make  clean  the  skin. 

To  all  the  organs,  to  the  still  strongly-beating  heart,  and 
to  the  over- worked  muscles,  there  is  allowed  a  period  of  re- 
pose. When  the  operation  day  arrives,  the  patient  has 
become  acclimatised,  strict  confinement  to  bed  and  a  limited 
diet  do  not  involve  so  very  sudden  a  change,  he  has  adjusted 
himself  to  his  new  environment,  and  the  ordeal  is  met  after 
a  period  of  physiological  rest. 

The  same  applies  equall}'  to  surgery  in  private  life.  Many 
a  surgeon  has  regretted  an  operation,  performed  on  the  spur 
of  the  moment,  in  his  own  consulting  room,  and  the  patient 
has  Hved  to  place  a  peculiar  construction  upon  the  operator's 
definition  of  a  "  mere  trifle  "  or  a  "  mere  prick." 

Many  small  operations  would  do  infinitely  better  if  the 
patient  would  consent  to  the  preliminary  of  a  few  days'  rest. 
This  is  conspicuous  often  in  operations  upon  piles,  when  the 
subject  persists  in  absorbing  himself  A\T.th  his  work  ujd  to  the 
time  of  the  operation.  Often  a  business  man  will  overwork 
himself  desperately  before  his  operation  in  order  that  his 
affairs  might  not  suffer  in  his  absence. 

What  is  worth  doing  at  all  is  worth  doing  well,  and  not  a 


24  OPERATIVE    SURGE  BY. 

few  operations,  tlie  performance  and  recovery  from  Avliich 
have  to  be  compressed  Avitliin  a  few  lim-ried  days,  had  better 
not  have  been  performed  at  all. 

Diet. — The  practice  of  starving  a  patient  before  an  opera- 
tion is  undoubtedly  unwise.  The  amount  of  the  food  should 
be  suited  to  the  condition  of  an  individual  who  is  inert  and 
Avithin  doors.  It  should  be  nutritious,  but  small  in  bulk,  and 
not  of  a  character  to  leave  much  debris  in  the  intestine. 
Entire  abstinence  from  alcohol  for  a  week  or  more  before  an 
operation  might  prove  very  judicious  in  not  a  few  instances. 
The  patient  who  "  keeps  himself  up "  by  spirits  before  an 
operation  is  preparing  for  himself  a  sore  do-wn-going  after  the 
event  is  over. 

The  Bowels. — The  bowels  should  be  well  opened  on  the 
eve  of  the  operation ;  and  this  is  best  effected  by  an  aperient 
overnight  and  an  enema  in  the  morning:. 

Cleanliness. — Care  should  be  taken  that  the  patient's  body 
is  clean.  A  warm  bath  on  the  night  before  the  operation 
is  desirable  whenever  possible,  and  a  source  of  comfort  to  the 
patient. 

The  part  to  be  operated  upon  should  be  especially 
cleansed.  The  skin  should  be  well  rubbed,  or  even  scrubbed, 
with  soap  and  water,  and  may  be  afterAvards  more  thoroughly 
purified  by  being  covered  for  some  hours  with  a  towel  soaked 
in  carbolic  lotion. 

The  shaving  off  of  the  axillary  or  pubic  hair — when  an 
operation  concerns  those  regions — might  be  postponed  until 
the  patient  is  being  anaesthetised. 

Clothing.— The  body  should  be  well  and  warmly  clad 
during  an  operation.  Not  a  little  of  the  shock  that  often 
follows  a  long  operation  may  be  due  to  the  fact  that  the 
patient  has  been  lying  nearly  naked  upon  a  table,  for  an  hour 
or  more,  possibly  in  a  cold  room,  and  exposed  to  the  further 
chiUing  action  of  wet  ap2:»lications.  This  precaution  applies 
especially  to  old  persons  and  to  the  winter  time.  So  long  as 
the  part  to  be  dealt  with  is  well  exposed,  the  rest  of  the  body 
cannot  be  too  well  protected,  and  liberal  use  should  be  made 
of  blankets,  warm  woollen  stockings,  woollen  jerseys,  jackets, 
and  the  like. 

The  night-dress  to  be  Avorii  after  the  operation  should  be 


TJIE    HOUR    FOR    THE    OPERATION.  25 

divided  down  the  back,  so  that  it  may  be  removed  without 
disturbing  the  patient.  The  form  of  flannel  jacket  called  by- 
nurses  a  "  nightingale  "  is  very  useful,  especially  for  patients 
who  can  sit  up  in  bed. 

In  the  case  of  women  with  long  hair,  the  various  coils 
and  twists  should  be  undone,  the  whole  hair  parted  behind 
in  the  median  line  and  disposed  of  in  two  simple  lateral 
plaits.  The  hair  is  thus  kept  out  of  the  way — should  the 
operation  concern  the  head  and  neck — and  after  the  operation 
the  head  can  rest  comfortably  upon  the  natural  scalp,  and 
not  upon  a  comphcated  mound  of  wisps  of  hair,  hair-pins, 
and  other  foreign  substances. 

The  Hour  for  the  Operation. — The  most  convenient  time 
for  an  operation  is  the  early  morning,  say  between  eight  and 
ten  a.m.  As  the  patient  should  have  no  food  for  five  hours 
before  he  is  anaesthetised,  this  appointment  involves  the  omis- 
sion of  no  meal  but  breakfast.  If  he  has  slept  well,  there  is 
little  time  between  his  sleep  and  the  surgeon's  coming  in 
which  to  ruminate  and  to  foster  an  alarm.  Should  any 
serious  compHcation  occur  within  a  few  hours  of  the  opera- 
tion, it  will  be  daylight,  and  prompt  assistance  wiU  probably 
be  at  hand. 

The  above  observations  apply  to  the  preparing  of  a  patient 
for  an  operation  of  some  magnitude.  They  apply  in  propor- 
tionate degree  to  procedures  of  lesser  gravity.  For  certain 
measures  special  preparations  have  to  be  made.  These  are 
described  in  the  sections  which  deal  with  them. 


26 


CHAPTER    II. 

The    Operator. 

The  surgeon,  according  to  the  oft-quoted  axiom  of  Celsus, 
should  be  young.  By  this  it  is  to  be  inferred  that  he  should 
be  possessed  of  the  muscular  strength,  the  courage,  the  sure- 
ness  of  hand  and  the  keenness  of  eye,  which  are  assumed  to 
be  the  quahties  of  youth. 

Operative  surgery  is  a  handicraft,  and  the  accomplished 
operator  must  lay  claim  to  be  considered  a  skilled  handi- 
craftsman. Like  other  and  simpler  handicrafts,  much  in  the 
attainment  of  success  depends  upon  natural  aptitude  and 
physical  quahfication;  but  still  more  depends  upon  culture 
and  patient  practice.  A  well-matured  and  well-balanced 
judgment  guides  the  hand  of  him  who  shows  most  skill ;  he 
may  do  well  who  is  bold,  but  he  will  do  better  who  has  pre- 
cise knowledge.  The  surest  sense  of  confidence  rests  with  the 
o]3erator  who  knows  accurately  what  he  intends  to  do,  and 
how  to  do  it.  The  least  success  follows  the  hand  of  the  man 
who  retains  throughout  an  operation  a  speculative  spirit, 
who  depends  largely  upon  his  imagination  for  conditions, 
and  upon  the  fortune  of  events  for  results.  A  shakiness  of 
the  hand  may  be  some  bar  to  the  success  of  an  operation,  but 
he  of  a  shaky  mind  is  hopeless.  In  the  handling  of  a  sharp 
instrument  in  connection  with  the  human  body  a  confusion 
of  the  intellect  is  worse  than  chorea. 

The  actual  manipulative  part  of  surgery  requires  no  very 
great  skill,  and  many  an  artisan  shows  infinitely  more  adept- 
ricss  in  his  daily  work.  A  wood  engraver  would  probably 
soon  find  as  little  difficulty  in  baring  the  carotid  artery  as  a 
stone  carver  would  find  in  performing  osteotomy. 

It  is  in  the  mental  processes  involved  in  an  operation 
that  not  a  few  fail.  There  is  some  lack  in  the  precision,  the 
strained  attention,  the  art  to  meet  any  possibility,  and  the 


THE    OPEBATOIi.  27 

capacity  for  forming  a   ready  judgment,  which  must  follow 
each  movement  of  the  surgeon's  knife. 

Some  of  the  most  incredible  examples  of  surgical  blun- 
dering, such  as  the  fashioning  of  flaps  in  such  a  way  as  to 
amputate  the  trunk  from  the  limb,  and  the  opening  of  the 
stomach  in  mistake  for  the  colon  in  performing  lumbar 
eolotomy,  are  calamities  due  to  mental  rather  than  to  physical 
defects. 

The  mere  handicraftsmanship  of  surgery  depends,  as  has 
been  already  said,  not  only  upon  natural  physical  endow- 
ments, but  also  upon  careful  practice  and  education.  Some 
men  are  born  with  steady,  dexterous  fingers  and  precise  and 
quick-moving  muscles;  others  overcome,  with  more  or  less 
success,  a  congenital  and  obstinate  clumsiness. 

Every  pams  should  be  taken  to  cultivate  what  may  be 
termed  a  surgical  hand.  A  shaky  hand  may  be  born  with 
its  possessor,  and  may  remain  unaffected  by  any  attempts  to 
amend  it.  This  important  defect  may  also  be  developed  by 
irregular  modes  of  living,  by  the  moderate  use  of  alcohol,  and 
by  smoking.  The  effect  of  tobacco  is  obvious  enough  in 
most  instances,  although  its  influence  may  be  very  transient. 

The  full  use  of  the  larger  muscles  as  developed  by  vigorous 
athletic  exercises  adds  distinctly  to  the  steadiness  of  the 
hand,  and  of  his  general  muscular  development  an  operator 
should  be  most  careful.  Athletic  exercises,  involving  the  upper 
limbs,  such  as  fencing,  rowing,  and  practice  in  a  gj^mnasium, 
certainly  render  the  hand  for  some  hours  after  such  exercise 
unsteady,  although  after  a  longer  period  of  rest  precision  in  the 
action  of  the  smaller  muscles  is  with  equal  certainty  improved. 
In  connection  with  this  point,  it  is  needless  to  say  that  violent 
exertion  on  the  part  of  the  operator  is  not  wise  immediately 
before  an  operation.  A  surgeon  who  is  careful  of  the  manner 
in  which  his  scalpel  is  held  should  not  caiTy  a  heavy  bag  to 
the  scene  of  his  labours,  nor  should  he  take  part  in  such 
muscular  exertions  as  are  needed  to  move  operating  tables 
or  beds,  or  to  lift  a  heavy  patient.  The  vigorous  efibrts 
which  may  be  necessary  to  restrain  the  violence  of  a  patient 
under  chloroform  are  apt  to  render  the  arms  of  those  so 
engaged  very  tremulous. 

The  action  of  the  palmar  muscles  can  be  very  admirably 


28  OPERATIVE    SURGERY. 

developed  by  such  occupations  for  a  leisure  hour  as  etchmg- 
on  copper,  sketching,  or  wood  carving. 

A  knowledge  of  anatoony  is  essential  to  the  operatmg 
surgeon.  Such  knowledge  as  is  needed,  however,  is  not  to 
be  obtained  from  books  alone,  or  even  from  books  in  pre- 
ponderating degree.  It  must  be  such  "anatomy"  as  is  to 
be  acquired  by  long  work  in  the  dissecting-room,  and  it  may 
not  be  too  much  to  say  that  he  Avho  would  deliberately  adopt 
the  career  of  an  operating  surgeon  should  have  served  for 
some  years  the  dreary  apprenticeship  involved  by  the  duties 
of  a  demonstrator  of  anatomy. 

Such  work  teaches,  not  only  the  jDosition  and  relation  of 
parts,  but  it,  and  it  alone,  can  instil  into  the  mind  and  the 
fingers  a  proper  appreciation  of  tissues,  and  the  knowledge 
of  what  may  be  termed  the  anatomy  of  the  individual.  A 
surgeon  may  know  well  the  origin,  insertion,  and  relations  of 
the  parietal  muscles  of  the  abdomen,  but  he  who  has  dis- 
sected and  demonstrated  the  lumbar  region  in  "subjects"  of 
all  kinds,  many  times  over,  has  also  h,  knowledge  of  the 
depth,  the  thickness,  the  appearance,  and  the  disposition  of 
the  tissues,  not  as  they  lie  in  an  abstract  body,  but  as  they 
may  be  expected  to  be  found  in  individuals  of  different  types. 

Moreover,  the  work  of  dissection  affords  the  most  ex- 
cellent training  in  the  handicraftsmanship  of  the  future 
operator. 

Precision  of  knowledge,  precision  in  judgment,  precision  of 
hand,  are  all  needed  in  a  surgical  operation.  They  are  the 
foundation  of  the  coolness  and  the  sang-froid  with  which  a 
surgeon  is  presumed  to  be  possessed,  and  it  is  to  their  absence 
that  can  usually  be  ascribed  that  condition  of  mind  known 
as  "  surgical  delirium." 

He  who  is  about  to  undertake  an  operation  should  know 
precisely  what  he  intends  to  do,  and  should  then  proceed 
to  do  it.  He  should  have  estimated  probabilities,  and  be 
quite  aware  of  his  mode  of  dealing  with  them. 

The  individual  who  plunges  into  an  operation  with  an 
uncertainty  he  would  condcnni  in  the  pursuit  of  an  ordinary 
business  undertaking,  and  who  discards  anatomical  precision 
for  the  old  maxim  "  cut  and  tie,"  is  likely  to  reap  the  reward 
of  his  labours. 


THE    OPERATOR.  i!9 

The  surgeon's  'precision  should  apply  to  every  detail  of 
the  operation  and  its  surroundings.  He  should  select  and 
arrange  and  examine  his  instruments  with  the  greatest  care ; 
should  consider  himself  responsible  for  the  minutest  detail  in 
the  needed  arrangements ;  and  should  have  a  proper  respect 
for  the  magnitude  of  small  things. 

The  introduction  of  anesthetics  has  very  greatly  altered 
the  circumstances  of  operative  surgery,  as  it  has  transformed 
the  surroundings  of  the  operation  table. 

It  is  no  longer  a  point  of  primary  importance  that  a  stone 
should  be  extracted  in  a  few  seconds,  or  a  limb  removed  in  a 
limited  number  of  minutes.  A  pupil  with  a  Avatch  in  his 
hand  no  longer  stands  beside  the  struggling  and  shrieking 
patient  to  take  "  the  time."  The  days  of  the  so-called 
"  brilliant "  surgeon  are  over.  Brilliancy,  as  now  associated 
with  operations,  will  probably  concern  the  reckless  mani- 
pulations of  an  irresponsible  hand,  or  the  fortunate  thrusts 
of  the  overbold.  It  belongs  to  the  surgical  "  ft-ee  lance,"  and 
is  associated  with  manj^  l^'^ppy  results,  and  with  many  more 
which  are  lamentable. 

The  operating  theatre  of  a  large  hospital,  and  the  presence 
of  an  audience  of  enthusiastic  and  marvel-loving  students, 
offer  a  great  temptation  for  the  display  of  theatrical  effect, 
and  encourage  a  disregard  for  other  than  immediate  results. 

The  time  is  even  now  not  long  past  when  a  surgeon 
would  "whip  off"  a  leg  or  remove  a  stone  with  something  of 
the  fever  and  eclat  of  a  conjurer  who  draws  an  unexpected 
rabbit  from  his  sleeve. 

The  assistants  at  an  operation  have  an  exceedingly  im- 
portant office  to  fill,  and  their  capacity  for  their  Avork  must 
necessarily  vary.  It  is  a  part  of  an  operator's  duty  to  see  that 
each  assistant  is  fully  informed  of  what  he  has  to  do,  and, 
if  possible,  of  the  manner  of  his  doing  it.  An  unsuccessful 
operation  is  often  attended  by  much  abuse  of  the  assistants, 
and  by  very  severe  criticisms  of  their  manipulative  powers. 
Such  condemnation  may  be  just,  or  may  only  serve  to  illus- 
trate the  proverb  that  "a  bad  workman  complains  of  his 
tools."  It  is  during  the  most  perplexing  stages  of  an  opera- 
tion, and  when  things  are  going  ill,  that  the  indifferent 
operator  finds  that  knives  will  not  cut,  that  forceps  Avill  not 


30  OPERATIVE    SUBGEBY. 

hold,  and  that  the  chimsiness  of  assistants  is  beyond  the 
limits  of  human  behef 

In  the  matter  of  chess,  the  operator  should  be  "  in  his 
shirt-sleeves,"  -wdth  his  arms  bare,  and  clothed  from  his  collar 
to  his  feet  in  a  simple  macintosh  apron.  The  practice  of 
wearing  an  ancient  and  discarded  frock-coat,  which  repeated 
operations  have  rendered  stiff  with  blood,  is  not  consistent 
with  the  rudiments  of  antiseptic  surgery.  If  the  surgeon 
must  wear  a  coat,  let  it  be  an  entirely  new  one. 

Sleeves  of  macintosh,  or  of  any  other  material,  are  ob- 
jectionable, clumsy,  and  in  the  way. 


31 


CHAPTER   III. 

The   Operating-Room. 

The  Room. — Of  the  operating  theatres  and  operating 
wards  of  hospitals  it  is  not  necessary  to  speak.  It  must  be 
assumed  that  they  have  been  constructed  upon  an  accepted 
plan,  and  are  equipped  to  the  satisfaction  of  those  who  are 
responsible  for  the  treatment  carried  out  in  them. 

On  the  other  hand,  no  little  care  has  to  be  exercised  in 
selecting  and  preparing  a  room  in  a  private  house  for  an 
operation  of  importance. 

It  is,  in  the  lirst  place,  essential  that  the  house  be  in  a 
perfectly  sanitary  condition,  and  as  it  appears  to  be  an  article 
of  the  householder's  faith  that  the  hygienic  state  of  his  or  her 
premises  is  exceptionally  perfect,  it  is  well  that  the  building 
should  be  examined  by  a  skilled  person  without  the  re- 
sidential bias. 

On  the  night  before  the  operation  the  patient  should  sleep 
in  a  room  other  than  that  in  which  the  operation  is  to  be 
performed.  The  operating-room  can  then  be  prepared  at 
leisure,  and  without  the  patient's  direct  knowledge.  It  is  in 
this  room  that  the  patient  should  remain  during  the  after- 
treatment.  A  second  bed  will  probably  be  required  for  a 
nurse.  As  Mr.  Doran  well  puts  it,  "  the  apartment,  speaking 
in  general  terms,  should  be  large  enough  for  two  people  to 
live  and  sleep  in  for  several  weeks,  according  to  current 
authorities  in  hygiene." 

The  room  should  be  made  as  nearly  like  a  hospital  ward 
as  possible.  The  carpet  and  all  unnecessary  hangings  and 
curtains  should  be  removed.  It  should  be  bared  of  all  but 
absolutely  essential  furniture.  The  walls  should  be  brushed 
down  and  the  floor  scrubbed,  and  the  room  may  be  weU  ven- 
tilated on  the  previous  day  by  open  windows  and  a  large  lire. 

The  practice  of  allowing  a  carbolic  spray  to  be  at  work 


32  OPERATIVE    SURGERY. 

in  the  room  for  some  hours  before  the  operation  is  commend- 
able, especially  in  the  croAvded  houses  of  a  large  to-\\Ti. 

The  room  should  be  quiet,  light,  and  Avell  ventilated,  and  is 
pleasanter  if  its  windows  look  towards  the  south.  It  should  not 
be  near  a  water-closet.  An  open  fireplace  is  most  desirable, 
and  the  less  gras  burnt  in  the  room  the  better.  It  should  be 
ascertained  that  the  windows  open  readily.  The  table  should 
stand  upon  a  square  of  drugget,  for  a  carpetless  polished  floor 
is  apt  to  be  dangerously  sHppery. 

The  teniperature  of  the  room  during  and  after  the  opera- 
tion should  be  kept  at  about  60°  to  65°,  and  should  not  be 
allowed  to  fluctuate. 

The  Patient's  Bed. — The  patient's  bed  should  be  a  narrow, 
simple,  iron  bedstead,  with  a  woven  spring  body,  upon  which 
is  placed  a  horsehair  mattress.  There  should  be  no  rail  on 
either  side,  and  but  a  low  one  at  the  head  or  foot.  The  bed 
should  be  so  located  in  the  room  that  the  patient  avlU  be 
accessible  from  all  sides,  and  the  wound  be  dressed  with  ease. 

It  is  usually  most  convenient  that  the  bed  should  stand 
in  the  centre  of  the  room — probably  in  the  place  occupied  by 
the  operating  table — and  be  so  arranged  that  the  head  is 
towards  the  light,  that  is  to  say,  as  the  individual  lies  in  bed 
the  light  wiU  be  behind  him. 

A  bed  in  a  corner  is  always  inconvenient,  and  may  in  a 
case  of  sudden  secondary  haemorrhage  be  a  source  of  danger, 
the  patient  being  accessible  from  one  side  only. 

To  allow  a  heavy  patient,  after  a  serious  operation,  to 
return  to  a  large  wide  bedstead,  covered  by  a  voluminous 
feather  mattress,  into  the  centre  of  which  the  helj)less  in- 
dividual sinks,  is  to  place  him  in  a  position  of  some  peril. 

After  many  operations  a  bed-cradle  will  be  required.  In 
some  cases  a  "  bed  puUey  "  may  be  conveniently  affixed  to  the 
joist  of  the  ceiling  over  the  head  of  the  patient's  bed. 

Accessories. — The  other  accessories  are  a  large  table  for 
the  basins  and  one  or  more  small  and  light  tables  for  the 
instruments.  The  instrument  table  should  be  on  wheels,  so  as 
to  be  readily  moved  when  required.  A  large  vessel  in  which  to 
first  rinse  the  sponges  as  they  are  handed  back,  soaked  with 
blood,  etc.,  to  the  nurse,  is  desirable,  and  for  this  a  china  foot- 
bath answers  admirably.      Keceptacles   are   needed   for  the 


THE    OPERATING    TABLE.  33 

dirty  water,  and  possibly  for  such  evacuations  as  ascitic  thud 
or  the  contents  of  an  ovarian  cyst. 

A  Hberal  supply  of  hot  water  should  be  at  hand,  and  a 
suitable  pro^dsion  of  pillows,  towels,  and  macintosh  sheets, 
together  with  the  usual  nursing  accessories.  In  Mr.  Mayo 
Robson's  valuable  little  book,  "  A  Guide  to  the  Instruments 
and  Appliances  required  in  Various  Operations,"  is  a  detailed 
list  of  the  articles  actually  needed  both  in  the  operating-room 
and  the  patient's  bed-room.  Another  valuable  pamplilet  is 
Dr.  Keen's  on  "  The  Organization  of  an  Operation." 

The  Operating  Table. — The  table  employed  should  be 
simple,  strong,  and  steady.  It  is  essential  that  it  should  be 
narrow,  and  of  a  height  convenient  to  the  individual  operating. 
A  table  with  the  following  measurements  will  be  found  con- 
venient :  length,  5  to  6  feet ;  width,  2  feet ;  height,  33  inches.  It 
should  be  covered  by  either  a  thin,  firm  horsehair  mattress, 
or  by  a  large  and  lieatly-folded  blanket.  The  latter  is  the 
more  convenient  in  operations  performed  in  private  houses. 

The  plan  of  having  two  small  tables  placed  in  the  form 
of  the  letter  T  is  decidedly  inconvenient.  It  should  be  re- 
membered that  the  table  may  need  to  be  moved  during  the 
operation.  For  example,  in  the  removal  of  the  tongue,  with 
preliminary  ligation  of  the  Imgual  arteries  in  the  neck,  it  is 
not  often  that  the  table  can  be  so  placed  that  the  light  fails 
equally  well  upon  both  sides  of  the  neck.  As  a  good  light  is 
very  essential  for  this  procedure,  the  table  may  have  to  be 
placed  in  one  position  while  the  left  artery  is  being  secured, 
and  in  another  when  the  right  is  dealt  with.  A  slender,  un- 
steady table  may  prove  a  source  of  actual  danger.  I  have 
seen  a  table  give  way  entirely  while  the  struggles  of  the 
patient  were  being  restrained  during  the  early  stages  of 
anffisthetisation. 

The  crazy  contrivances  and  makeshifts  which  the  patient's 
friends  sometimes  consider  to  be  ingenious  substitutes  for  a 
proper  table  are  to  be  distinctly  avoided.  I  have  a  recol- 
lection of  one  altar-like  construction,  made  of  four  boxes  and 
a  small  chest  of  drawers,  upon  which  was  recumbent  a  heavy 
man,  prepared  for  an  excision  of  a  part  of  the  lower  jaw. 

The  best  operating  table  vnth  which  I  am  acquainted  is 
that  designed  by  Professor  William  Rose,  of  King's  College, 


34 


OPERATIVE    8UBGEBY. 


and  Dianiifactiircd  by  Roskilly.  It  is  in  use  at  many  of 
the  metropolitan  hospitals.  It  is  strong,  but  light,  and  is 
in  every  way  remarkably  convenient. 

The  table  is  very  steady,  but  by  the  action  of  a  simple 
lever  is  at  once  raised  upon  wheels,  and  can  then  be  moved 
about  readily  while  the  patient  is  lying  upon  it. 

The  head  and  shoulders  can  be  raised  to  any  angle  by  a 
simple  screw  mechanism.  By  another  contrivance,  the  in- 
clination of  the  whole  trunk  can  be  altered  in  a  moment.  By 
an  equally  convenient  apparatus,  both  lower  limbs  can  be 
flexed  at  the  knee  and  hip  joints.  The  '  leg  pieces "  of  the 
table  can  be  placed  at  any  angle,  or  can  be  removed,  as  would 
be  necessary  in  amputation  of  the  lower  limb.  While  the 
patient  is  in  the  lithotomy  position,  the  buttocks  can  be 
elevated  or  lowered  as  required,  and  with  the  utmost 
readiness. 

Although  capable  of  manifold  adjustments,  the  table 
cannot  be  said  to  be  complicated,  and  so  far  as  strergth  is 
concerned  it  has  well  stood  the  test  of  time. 

The  Arrangement  of  the  Tables,  etc. — The  operatmg  table 


Dressjnfrs. 


Table  for  Basins,  &c. 


Morse.  (^ 


Q  Nursft 


Chief  Assistant. 


O  O     /> 

Second  Assistant.  Surgeon.    / 


Spare  Instraments. 


Fro.  1.  — DTAOR.\M    SHOWING   AKUANGKMKNT  OP  .SURGEON'.S   TABLKS. 


THE    OPERATING    TABLE.  35 

should  be  placed  in  the  best  attainable  light,  and,  in  the 
case  of  most  operations,  with  the  patient's  feet  towards  the 
windows.  If  there  be  tAvo  windows  near  together  in  the  same 
wall  of  the  room,  the  table  may  be  so  placed  as  to  be  at  right 
angles  to  the  wall,  and  to  have  its  foot  opposite  the  space 
between  the  two  sources  of  light.  There  should  be  sufficient 
room  on  all  sides  of  the  table  to  alloAV  an  individual  to  pass 
freely. 

The  general  J^isposal  of  the  tables,  and  of  the  surgeon  and 
his  assistants,  is  illustrated  in  the  diagram  (Fig.  1),  which 
may  be  considered  to  relate  to  such  an  operation  as  the 
radical  cure  of  hernia  or  the  removal  of  a  tumour  from  the 
thigh. 

The  anaesthetist  stands  at  the  head  of  the  table,  and  the 
operator  on  the  patient's  right.  Close  to  the  surgeon's  right 
hand  is  a  light  table  for  the  necessary  instruments. 

A  larger  table  for  accessory  and  spare  instruments,  and 
for  such  apparatus  as  the  thermo-cautery,  etc.,  may  be  placed 
at  a  distance  behind  the  operator. 

The  chief  assistant  stands  on  the  left  side  of  the  table, 
opposite  the  surgeon.  It  is  by  this  assistant  that  the 
sponging  is  done  and  the  haemorrhage  attended  to. 

Behind  this  assistant,  and  entirely  to  the  left,  is  a  large 
table  for  the  basins  needed  for  the  sponges,  and  for  receivers, 
jars  of  lotion,  etc.,  and  at  this  table  the  two  nurses  are  placed. 

A  smaller  table  may  stand  close  to  the  larger  one  to  take 
the  dressings  necessary  for  the  case 

A  second  assistant  may  place  himself  to  the  operator's  left 
and  upon  the  right-hand  side  of  the  operating  table. 


D  2 


36 


CHAPTER   IV. 

The  Instrumexts  and  Accessories. 

The  operator  should  attend  personally  to  the  selection  and 
care  of  all  instruments,  and  to  the  minutest  matters  which 
concern  them. 

They  should  be  in  perfect  condition,  and  above  all  things 
clean.  Dissecting  forceps  and  pressure  forceps  are  often 
found  with  the  teeth  clogged  with  the  blood  from  the  last 
operation,  or  with  the  greasy  black  compound  with  which 
they  have  been  last  cleaned  at  the  instrument-maker's. 
Trocars,  directors,  and  probes  need  very  careful  cleaning, 
and,  although  the  blade  of  a  knife  may  be  brilliant,  its  rough 
handle  may  be  filthy. 

An  ojiportunity  is  sometimes  afforded  of  inspecting  the 
instrmnents  in  a  httle-used  pocket  case,  and  their  condition  is 
occasionally  open  to  unpleasant  criticism. 

Ingenious  instruments  which  fold  up  into  a  small  compass, 
or  which  combine  many  functions,  are  usually  to  be  avoided. 

In  the  selection  of  instruments,  each  manipulator  must 
exercise  his  own  taste,  and  found  his  choice  upon  his  habit 
of  hand-  It  is  improbable  that  twenty  men  would  select  the 
same  pen  or  pen-holder  out  of  a  collection  of  twenty  samples, 
but  they  might  all  ■write  equally  AvelL 

There  is  no  doubt  but  that  the  fewer  the  implements  to 
which  a  surgeon  accustoms  himself,  and  the  simpler  they  are, 
the  better.  As  has  been  already  said,  the  surgeon's  work  is 
a  handicraft.  He  should  depend  more  upon  his  fingers  than 
upon  his  tool  He  who  is  really  expert  with  one  instrument 
has  an  advantage  over  him  who  is  indifferently  familiar  Avith 
many. 

The  best  work  is  done  \vith  the  simplest  implements.  A 
surgeon  who  is  dependent  upon  a  special  instrument  for  this 
and  a  special  instrument  for  that,  is  a  poor  handicraftsman. 


THE    INSTRUMENTS.  37 

He  is  servilely  subject  to  his  special  forceps  and  his  particular 
knives  and  needles  for  a  particular  operation.  An  intending 
subject  for  operation  may  well  measure  the  depth  of  his  sigh, 
at  the  sight  of  the  surgeon,  by  the  size  of  the  operator's  in- 
strument bag. 

Some  of  the  least  progressive  periods  in  the  development 
of  the  surgeon's  art  have  been  marked  by  the  prolific  pro- 
duction of  instruments.  With  few  exceptions,  complex 
apparatus  and  appliances  which  are  credited  with  being 
ingenious,  or  labour- savino",  or  automatic,  are  bad. 

A  great  multitude  of  the  instruments  which  figure  in  the 
makers'  catalogues  are  evidences  of  incompetence,  and  of  a 
lack  of  dexterity  which  prevented  the  inventor  from  making 
full  use  of  his  hands. 

On  turning  over  the  pages  of  such  catalogues,  one  is 
struck  by  the  circumstance  that  among  the  very  numerous 
names  of  designers  of  instruments  there  are  but  very  few 
belonging  to  surgeons  who  are  or  have  been  eminent  as  first- 
class  operators.  It  is  true,  moreover,  that  among  what  may 
be  termed  modern  new  instruments,  the  chief  of  those  which 
have  come  into  immediate  and  general  use  are  accredited  to 
famous  operators.  With  such  may  be  named  the  bone  forceps 
and  lion  forceps  of  Fergusson,  Liston's  amputating  knives, 
Syme's  knives,  and  the  ovarian  trocar  and  pressure  forceps 
of  Sir  Spencer  Wells. 

A  great  deal  can  be  done  in  operative  surgery  with  a 
scalpel  and  a  pair  of  dissecting  forceps,  and  indeed  there  is 
but  comparatively  little  that  cannot  in  some  way  be  accom- 
plished with  those  instruments. 

A  brief  notice  is  here  given  of  the  simplest,  most  general, 
and  most  essential  instruments.  The  special  instruments  are 
considered  in  the  chapters  dealing  with  the  procedures  with 
which  they  are  concerned. 

The  Scalpel  should  be  light,  and  should  have  a  handle  of 
good  length,  which  should  be  thin  and  quite  smooth. 

A  length  of  four  inches  for  the  handle,  and  a  width  of 
from  three-eighths  to  half  an  inch,  are  convenient.  A  shorter 
handle  does  not  rest  properly  in  the  hand ;  it  is  like  a  too 
short  pen-holder  or  paint-brush.  A  longer  handle  is  un- 
necessary. 


38  OPERATIVE    8UBGEBY. 

The  breadth  and  width  of  the  handle  may  possibly  vary 
•a  little  with  the  size  of  the  blade,  but  the  length  should  not 
vary.  A  scalpel  with  a  small  and  very  fine  blade  does  not 
need  a  handle  proportionately  reduced.  Indeed,  the  most 
excellent  small  scalpels  are  those  which  had  originally  blades 
of  good  size,  but  which,  have  been  reduced  to  slender  and 
short  proportions  by  repeated  grinding.  Although  small  in 
the  blade,  they  still  retain  the  original  handle. 

The  blade  should  be  what  instrument-makers  call "  middle- 
pointed  " — i.e.,  the  point  should  lie  on  the  long  axis  of  the 
steel  (Fig.  2  a). 

A  "  back-pointed  "  blade  is  not  well  suited  for  the  scalpel. 
It  answers  for  larg-er  knives,  which  are  broad  in  the  blade,  and 
are  required  to  make  large  and  fi-ee  incisions  ;  for  example, 
the  handiest  form  of  post-mortem  knife  and  of  cartilage  Itnife 
is  back-pointed. 

Very  fine  scalpels  are  a  grievous  delusion.  If  a  beginner 
IS  about  to  undertake  an  operation  involving  a  "fine"  dis- 
i^ection,  he  wiU  probably  seek  a  knife  with  a  very  fine  point, 
^uch  a  knife  is  depicted  in  Fig.  2,  b,  and  is  copied  fi'om  a 
catalogue  of  instruments.  It  is  a  useless  tool ;  it  is,  indeed,  a 
needle,  not  a  loiife.  A  surgeon  who  once  attempts  to  per- 
form a  fine  plastic  operation  with  such  an  instrument  will 
probably  discard  the  knife  for  ever. 


Fig.  2. — (a)  good  scalpel  ;   (b)  bad  scalpel.     (From  a  moderu  catalogue 
of  instruments.) 

A  small  scalpel,  with  a  good  blade  and  a  "  middle  point," 
and  with  such  an  outline  as  is  depicted  in  Fig.  2,  a,  is  the  best 
•nstrument  for  the  finest  work  the  operator  can  be  called 
upon  to  perform.  The  very  fine  back-pointed  knife  will 
scratch,  but  it  will  not  cut. 


THE    INSTRUMENTS. 


39 


The  back  of  a  soalpel  should  be  blunt  up  to  the  very 
point.  Double-edged  knives  are  purposeless — in  any  ordinary 
operation — and  the  surgeon's  fingers  are  apt  to  be  cut  by 
them. 

The  ordinary  forms  of  bistoury  have  handles  somewhat 
more  substantial  than  those  of  scalpels,  and  they  are  con- 
venient if  a  little  roughened,  but  the  length  of  the  handle 
need  not  be  much  in  excess  of  that  of  the  scalpel. 

A  straight  probe-pointed  bistoury,  with  a  blade  two  and 
a  half  inches  in  length,  is  the  most  useful  instrument  of  the 
olass. 

Dissecting  Forceps  should  have  a  good  spring,  should  be 


Fior.  3. — STOUT  iitsskcting  forceps. 


short,  and  should  not  be  too  narrow  at  the  points.  Four  and 
a  quarter  inches  is  a  very  convenient  length.  Dissecting  for- 
ceps are  not  uncommonly  too  lightly  and  too  frailly  made  to 
be  serviceable.  The  strength  of  the  spring  must  depend  upon 
individual  taste.  For  all  ordinary  purposes  a  good  broad 
point  is  desirable ;  it  enables  the  surgeon  to  obtain  a  firm 
gras]D  of  the  tissues,  and  at  the  same  time  does  not  prevent  a 
very  small  fragment  of  tissue  from  being  picked  up  (Fig.  3). 


L-lii.  4. — SPENCER    WELLS'S  ARTEKY    FORCEPS. 


40  OPERATIVE    SURGERY. 

Artery  Forceps. — The  pressure  forceps  of  Sir  Spencer 
Wells  are  simply  invaluable,  and  have  proved  to  be  one  of 
the  most  important  recent  additions  to  the  surgeon's  arma- 
mentarium. 

The  best  instruments  are  those  of  the  original  pattern 
(Fig.  4),  and  there  is  little  or  nothing  to  be  said  in  favour  of 
the  various  "  modifications  "  and  "  improved  forms." 

Of  the  different  varieties  of  artery  forceps,  the  best  is  that 
known    as    Wakley's    (Fig.   5).      They    pick    up   the    vessel 


Fig.  5.— wakley's  aeteey  forceps. 


cleanly,  retain  a  good  hold,  and  render  the  application  of 
the  hgature  efficient  and  easy. 

For  twisting  an  artery  no  especial  apparatus  is  required. 
"Wells's  pressure  forceps  form  the  simplest  torsion  forceps,  and 
may  take  the  place  of  many  of  the  comphcated  instruments 
known  by  the  latter  name. 

Retractors. — An  assistant's  fingers  form,  in  a  large  pro- 
portion of  all  operations,  the  best  retractors. 

In  certain  operations,  and  especially  in  the  case  of  deep 
wounds,  some  special  means  of  retracting  the  soft  parts  or 
the  skin  is  requu-ed. 

In  a  following  section  is  described  (page  55)  the  method 
of  retracting  the  skin  in  many  small  operations — such  as  the 
removal  of  a  superficial  tumour  or  the  radical  cure  of  varicocele 
by  means  of  ligatures.  This  method  leaves  the  area  of  the 
operation  wound  quite  free. 

To  draw  special  tissues  aside,  such  as  a  tendon,  a  nerve, 
or  a  vein,  blunt  hooks  answer  admirably.  They  take  up  little 
room,  and  encroach  but  httle  upon  the  area  of  the  operation. 
They  should  be  long  enough  and  large  enough  for  the  pur- 
pose, and  be  firmly  secured  in  handles. 

As  simple  wound  retractors,  the  handiest  and  the  most 
efficient  are  those  of  Farabeuf  (I'lg.  7),  which  are  made  in 
many  sizes.     The  little  turn  at  the  end  of  the  metal  gives 


THE    INSTRUMENTS.  41 

them  an  excellent  hold  of  the  tissues.     A  very  convenient 


Fig.  6, — farabeof's  modification  of  langenbeck's  retractor. 

instrument  also    is  Farabeuf's  modification  of  Langenbeck's 
retractor,  shown  in  Fi<j-.  6. 


Fig.  7. — fauabeuf's  retractor. 

These  are  excellent  substitutes  for  the  broad  copper 
spatulse  and  retractors  of  less  recent  times,  which  bent  when 
exposed  to  much  strain,  and  slipped  unless  that  strain  was 
kept  up. 

Needles. — The  best  suture  needle  is  a  perfectly  straight 
one,  of  a  length  adapted  to  the  case  in  hand,  and  "  triangular- 
pointed  "  (Fig.  8,  a).  Straight,  "  lancet-pointed  "  needles  are 
much  used,  but  they  are  not  so  serviceable  as  those  first 
named. 

For  special  operations  special  needles  a,re  required,  such 
as  in  suturing  intestine  and  in  operations  for  cleft  palate  and 
certain  fistulse,  but  for  all  ordinary  suture  purposes  the  best 
instrument  is  the  straight  needle. 

Many  surgical  needles  need  only  to  be  mentioned  to  be 
strongly  condemned.  These  are  the  large-curved  needles 
and  the  half-curved  needles  which  are  found  in  most 
pocket  cases,  and  which  are  currently  supposed  to  be  used 
for  sewing  up  wounds  of  the  scalp  (Fig.  8,  b).  If  any 
operator  acquires  perfect  control  over  these  unreasonably- 
shaped  needles  they  may  possibly  be  of  service.  I  have 
observed  a  half-curved  needle  to  be  introduced  at  one  spot 
and  its  point  to  emerge  at  another  at  some  distance  from  the 
intended  aperture.      The  surprised   operator  has  withdraAvn 


42  OPERATIVE    SUBGEBT. 

it,  and  on  making  another  attempt,  the  needle  point  has  again 
emerged  at  a  remote  and  imexpected  locahty. 

Hagedorn's  needles  are  excellent.  They  are  flat,  easily 
penetrate  the  skm,  and  make  a  small  and  clean  wound. 
This  wound  takes  the  form  of  a  narrow  sHt  at  right  angles 


Fig.  8. — (a)  straight  teiangular-pointed  suture  needle  ;    (bJ  half- 
curved  SUTURE  NEEDLE. 


to  the  line  of  the  incision  to  be  closed  by  suture,  and  the 
thread,  if  drawn  quite  tight,  cannot  greatly  enlarge  the  needle 
puncture.  It  must  be  confessed  that  the  comparative  value  of 
this  needle  has  been  exaggerated  by  its  inventor,  and  that  the 
evils  it  is  supposed  to  avoid  are  not  either  so  real  or  so  serious 
as  they  have  been  painted. 

Hagedorn's  diagram  ropresenting  the  terrible  gaping  and 
rending  of  the  needle  puncture  when  the  line  of  the  puncture 
is  parallel  to  the  line  of  the  operation  Avound,  depicts  a  con- 
dition that  I  have  never  met  with  in  real  Hfe.  This  needle  is 
of  service  in  conditions  where  a  straight  needle  is  less  easily 
introduced.  It  forms  an  excelbnt  intestinal  needle :  it  is 
useful  in  suturing  parts  which  are  placed  at  some  depth  in  a 
cavity,  it  is  usefid  in  hysterectomy,  in  operations  upon  the 
perineum,  upon  the  tongue,  the  palate,  and  the  scalp,  etc. 

The  best  forms  are  those  with  the  half-circle  or  the  three- 
eighth-circle  curve.  It  does  not  appear  that  any  advantages 
can  be  claimed  for  Hagedorn's  half-curved  needle  or  straight 
needle.  If  a  curved  needle  has  to  be  used  in  a  needle-holder, 
then  Hagedorn's  instruments  may  be  emplo3^cd. 

The  needle  holder  is  a  little  complex,  and  needs  practice 
before  it  can  be  deftly  handled.  It  is  difficult  to  keep  clean, 
and  the  suture  thread  is  very  apt  i,^  be  caught  between  the 
parts  of  the  apparatus. 

A  very  excellent  needle-holder  for  small  curved  needles  of 


SUTURE   MATERIAL.  43 

the   ordinary  pattern  is  tlie  simple  instrument   depicted    in 
Fig.  9. 

Hare-lip  pins,  or  suture  pins,  should  be  made  of  hard  steel, 
and  should  be  as  rigid  as  a  needle  of  corresponding  size.     It  is 


Fig.  9. — SIMPLE   NEEDLE-HOLDEK. 

not  uncommon  to  find  that  the  pin  is  of  so  soft  a  metal  that 
it  can  1)0  readily  bent  douljle  without  snapping. 

Suture  Material. — The  best  suture  material,  so  far  as  my 
experience  goes,  for  operation  wounds  of  almost  any  kind,  is 
silkworm  gut.  It  is  in  the  first  place  strong,  it  is  as  smooth 
as  glass  and  as  solid.  As  it  is  not  composed  of  fibres,  the 
fluids  of  the  wound  cannot  soak  into  its  substance,  and  there- 
fore if  it  be  retained  for  longer  than  the  usual  time  it  does 
not  act  as  a  seton.  I  have  frequently,  under  special  circum- 
stances, allowed  silkworm-gut  sutures  to  remain  in  position 
for  fourteen  days,  and  in  cases  of  cleft  palate  for  three 
weeks,  and  none  of  the  ordinary  evils  have  attended  the  prac- 
tice. 

In  the  case  of  many  wounds  which  require  support  for 
some  time  after  the  operation,  as  in  the  wound  left  after  the 
removal  of  a  mammary  tumour,  together  with  much  skin,  it  is 
better,  if  possible,  that  the  original  sutures  should  be  retained 
than  that  they  should  be  removed  and  their  place  taken  by 
strapping. 

Silk  sutures  must  be  removed  early.  It  is  not  to 
be  inferred  that  the  use  of  silkworm  gut  should  encourage 
the  practice  of  retaining  sutures  unduly.  A  suture  should  be 
removed  as  soon  as  it  can  be,  but  with  silkworm  gut  it  is 
possible  to  retain  the  support  of  the  suture  in  those  occa- 
sional cases  in  which  such  retention  is  of  advantage. 

In  the  next  place  silkworm  gut,  although  stiff,  moulds 
itself  to  the  position  it  is  made  to  assume  in  the  wound.  Its 
perfect   smootliness   renders   it   easy  to   introduce,  and   this 


Fifir.  10. — FIRST   STACK   OF   THE   SURGEON's    KNOT. 


U  OPERATIVE    SURGEBY. 

quality,  combined  with  its  pliability,  renders  it  easy  to  re- 
move. 

Silkworm-gut  sutures  should  be  allowed  to  soak  for  some 
ten  minutes  before  use  in  carbolised  water.  Such  immersion 
renders  them  less  slippery  and  less  stift*. 

The  suture  should  not  be  tied  in  a  knot.  If  a  knot  be 
attempted,  and  be  pulled  tight,  the  thread  is  almost  certain  to 
snap.  Like  metal  wire,  this  material  can  bear  a  great  strain 
in  a  straight  line,  but  it  is  apt  to  give  if  dragged  upon  when 
sharply  bent  upon  itself 

The  suture  is  secured  by  making  use  of  the  first  stage  of 
what  Fergusson  calls  the  surgeon's  knot,  "  which  is  made  by 
passing  one  end  of  the  thread  twice  over  the  other  (Fig.  10), 

before  turning  each 
back  again  to  form 
the  second  noose." 

With  silkworm 
gut  this  second  noose 
should  Eot  be  formed. 
The  thread  should  be  twisted  as  shown  in  Fig.  10,  and 
then  pulled  tight.  If  properly  applied  it  will  not  give.  In 
this  matter  of  securing  the  suture,  silkworm  gut  presents 
a  srreat  advantag-e  over  other  materials.  There  is  no  knot  to 
press  upon  the  tissues ;  the  interwoven  suture  threads  He 
absohitely  flat,  and  the  edges  of  the  Avound  are  approximated 
with  the  greatest  precision.  For  plastic  operations  and  for 
such  a  procedure  as  the  closure  of  a  ruptured  perineum,  this 
suture  material  is  invaluable.  The  threads  should  be  left  long, 
and  it  will  be  found  to  be  possible  to  loosen  or  tighten  the 
suture  after  it  has  been  "  tied,"  as  it  lies  in.nta. 

In  cases  where  the  fineness  of  the  resulting  scar  is  a  matter 
of  importance,  as  in  operations  upon  the  face  or  neck,  this 
material  should  alwa3^s  be  employed. 

Threads  of  two  or  three  different  sizes  can  be  obtained, 
and  the  red-stained  variety  is  the  more  convenient  as  being 
the  more  easily  seen. 

In  the  few  instances  in  which  silkworm  gut,  by  reason  of 
its  stiffness,  cannot  be  employed,  a  silk  suture  thread  may  be 
used.  The  form  of  silk  most  commonly  employed  is  that 
known  as  Chinese  twist.     This  material  has  a  disposition  to 


INSTRUMENT    TRAYS.  45 

kink  and  to  curl  up  even  after  it  has  been  soaked  in  water  for 
some  time. 

"  Turner's  patent  plaited  suture  silk  "  does  not  possess  these 
dis£vdvantages.  It  is  very  readily  applied,  presents  a  smoother 
surface  than  the  Chinese  twist,  and  is  apparently  the  best  form 
of  the  silk  suture  material. 

Ligature  Material. — Catgut  still  remains  the  material  best 
suited  for  ligatures,  especially  as  of  late  considerable  im- 
provements have  taken  place  in  its  manufacture. 

The  most  convenient,  and  apparently  the  best  variety,  is 
that  loioAvn  as  sulpho-chromic  gut,  which  is  dry,  and  sold  in 
definite  and  well-proportioned  sizes.  See  also  the  remarks 
upon  the  ligature  in  the  preliminary  section  on  the  Ligature 
of  Arteries. 

ACCESSORIES. 

Instrument  trays  are  essential.  Those  used  in  hospitals 
are  usually  made  of  white  china.  A  more  convenient  form  for 
private  practice  is  the  papier-mache  tray,  which  is  Ught,  not 
easily  broken,  inexpensive,  and  can  be  obtained  in  many  sizes. 

The  instruments  should  be  arranged  neatly  in  one  or  more 
trays,  and  should  be  classified,  i.e.,  the  cutting  instruments  in 
one  part,  the  forceps  in  another,  the  scissors  in  a  third. 

As  the  papier-mache  tray  is  dark,  needles,  which  are  not 
easily  seen  and  are  easily  lost,  may  be  placed  in  a  small 
saucer  by  themselves.  If  a  great  number  of  pressure  or  clamp 
forceps  have  to  be  at  hand,  they  may  be  conveniently  placed 
in  a  small  basin  with  steep  sides.  This  enables  them  to  be 
well  displayed,  and  prevents  them  from  becoming  entangled. 

The  trays,  basins,  etc.,  are  filled  with  a  one  in  thirty  solu- 
tion of  pure  carbolic  acid,  and  in  this  solution  the  instruments 
remain  immersed. 

An  irrigator  and  proper  receivers  are  necessary  in  all  but 
the  smallest  operations. 

A  wound  surfaca  should  be  cleaned  by  the  action  of  u 
steady  stream  of  carbolised  water,  and  not  by  the  rough 
rubbing  movements  of  a  vigorously  applied  sponge. 

A  large  conical  glass  irrigator,  with  a  tube  of  good  lumen, 
and  a  suitable  tap,  is  the  best  apparatus. 

A  syringe  is  in  most  cases  to  be  condemned.   It  is  awkward 


46  OPERATIVE    SURGERY. 

to  use,  is  apt  to  get  out  of  order,  involves  much  waste  of  time, 
and  sends  upon  the  wound  surface  an  ill-regulated,  spasmodic, 
and  usuall}'^  too  violent  stream  of  water. 

The  most  convenient  receivers  are  made  of  papier-mache 
or  hard  gutta-percha,  and  the  most  useful  form  is  that  known 
as  the  "  Iddne}'  shape." 

The  receiver  is  held  beneath  the  wound  surface,  and 
receives  the  fluid  from  the  irrigator  or  the  wrung-out  sponge. 

Sponges. — Ordinary  sponges  of  suitable  size  answer  well 
enough  for  the  majorit}^  of  cases.  In  abdominal  operations 
the  hnest  Turkey  sponge  should  be  used,  and  the  same  pro- 
vision may  be  made  for  plastic  procedures,  and  for  all  such 
operations  as  require  a  very  clear  view  of  the  depths  of  the 
wound.  Thus  in  securing  the  lingual  artery,  a  well-shaped 
Turkey  sponge  makes  no  little  difference  in  the  circumstances 
of  the  operation  when  the  vicinity  of  the  vessel  is  ap- 
proached. 

New  sponges  must  be  carefully  cleaned  and  freed  from 
every  particle  of  sand.  This  is  effected  by  having  them  well 
beaten  and  shaken  in  calico  bags,  and  by  then  immersing 
them  for  some  twenty-four  hours  in  Avarm  water,  in  which 
also  they  should  be  frequently  rinsed  out. 

Mr.  Doran  advises  that  the  sponges  should  then  bo- 
immersed  for  tAvelve  hours  in  a  one  in  live  solution  of  sulphur- 
ous acid.  This  serves  to  free  thom  from  all  organic  im- 
purities. 

The  method  recommended  by  Mr.  Greig  Smith  for 
cleansing  sponges  after  use  at  an  operation  is  very  efficacious. 

The  sponges  should  under  no  circumstances  be  boiled,  or 
even  placed  in  boiling  water.  They  should  be  lirst  well  Avashed 
and  rinsed  in  warm  water,  and  then  placed  in  a  solution  of 
ordinary  washing  soda  (about  a  pound  of  soda  being  cm- 
ployed  to  every  dozen  sponges).  This  solution  dissolves  out 
the  blood  and  tibrine,  and  in  it  they  are  repeatedly  washed 
and  squeezed.  When  every  particle  x)f  tilth  has  been  re- 
moved they  are  once  more  well  cleansed  in  water,  and  are 
then  allowed  to  stand  for  a  few  hours  in  a  one  in  twenty 
carbolic  solution. 

They  are  finally  squeezed  out  and  dried,  and  are  kept- 
in  a  dry  place  until  required  for  use. 


THE    STEAM   SFBAY.  47 

Masses  of  the  finest  absorbent  wool  rolled  up  so  as  to  be 
about  the  size  of  ordinary  sponges,  answer  well  in  many 
operations  in  the  place  of  sponges. 

Not  a  few  surgeons  discard  sponges  altogether. 

Sponges,  together  with  all  surgical  dressings,  are  most 
conveniently  stored  in  close-fitting  tin  boxes. 

The  Steam  Spray. — It  has  been  conclusively  sho^vii  that 
the  antiseptic  spray  is  not  essential  to  the  success  of  an 
operation.  By  the  great  majority  of  surgeons  its  use  has 
been  entirely  abandoned. 

It  is  still  retained  by  some  for  such  operations  as  involve 
the  opening  of  the  abdomen  or  the  pleural  cavity. 

Certain  surgeons  still  hold  that  no  abdominal  section  should 
be  performed  except  under  the  "protection"  of  the  spray:  others 
have  made  it  clear  that  abdominal  operations  of  every  degree 
can  be  carried  out  with  safety  and  success  quite  inde- 
pendently of  this  apparatus. 

The  question  of  the  use  of  the  spray  in  this  class  of  opera- 
tion is  well  discussed  by  Mr.  Greig  Smith  in  the  following 
passages : — "  Spray  or  no  spray  is  probably  a  choice  of  evils, 
and  of  not  very  great  evils.  On  the  one  side  the  evil  is 
irritation  of  the  peritoneum  from  the  germicide,  cooling  of 
the  peritoneal  surfaces  from  wetting  and  evaporation,  and 
poisoning  from  absorption  of  the  antiseptic  agent  used.  On 
the  other  side  the  evil  is  a  danger  to  be  avoided — nameh^ 
septic  peritonitis,  from  contamination  Avith  the  surrounding 
air.  Now,  there  is  no  doubt  whatever  that  the  greatest  risks 
of  peritonitis  arise  from  impurities  of  hands,  sponges,  and 
instruments,  and  not  from  air.  The  spray  has  little  influence 
over  these ;  but  repeated  cleansing  Avith  soap  and  water  will 
render  them  practically  pure.  An  antiseptician  who  scru- 
pulously attends  to  cleansing  of  hands  and  instruments  is  in  a 
better  position  than  one  who  places  all  his  trust  in  the  spray." 
It  must  be  allowed  that  the  spray  is  inconvenient  to  the 
surgeon,  and  that  the  moisture-laden  atmosphere  produced 
by  it  is  not  the  best  for  the  patient  to  breathe.  The  chief 
point  to  be  claimed  for  the  spray,  and  almost  the  only  point, 
is  that  it  tends  to  purif}^  the  atmosphere  around  the 
operating  table.  When  an  operation  is  performed  in  a 
healthy,  open,  country  place,  there   can   be    no   excuse   for 


48  OPERATIVE    SUBGEBY. 

the  use  of  this  somewhat  cumbrous  apparatus.  If  the  air 
be  acknowledged  to  be  pure,  the  steam  of  the  spray  is  a 
needless  addition  to  the  atmosphere.  On  the  other  hand, 
the  use  of  this  antiseptic  measure  would  appear  to  be  per- 
missible during  the  performance  of  an  abdominal  section,  in 
the  general  hospital  of  a  crowded  city.  The  theatre  in  such  an 
institution  may  be  close,  and  full  of  spectators  fresh  from  the 
dissecting  and  post-mortem  rooms  :  the  atmosphere  could  not 
be  considered  pure,  and  if  a  carbolised  spray  can  improve  its 
condition  it  should  certainly  be  employed. 


49 


CHAPTER    V. 

The  Elements  of  Operative  Surgery. 

The  Arrangements  of  the  Operating  Table. — The  surgeon, 
before  he  takes  the  knife  in  his  hand,  should  have  very 
clearly  made  up  his  mind,  not  only  what  he  intends  to  do, 
but  also  how  he  intends  to  do  it.  In  like  iiianner,  he  should 
precisely  instruct  his  assistants  as  to  their  duties  and  the 
manner  of  performing  them.  Each  man  should  have  his 
place  and  his  especial  office,  and  to  this  he  should  devote  his 
whole  attention. 

The  patient  should  be  placed  in  the  most  convenient 
position.  The  part  to  be  operated  upon  should  be  well  ex- 
posed. The  rest  of  the  body  should  be  neatly  and  carefully 
covered  up,  and  should  be  surrounded  by  precisely  folded 
macintoshes.  Not  one  particle  of  blanket  or  of  flannel  should 
be  visible.  The  "fluff"  of  these  materials  readily  comes  off 
on  the  wet  hand,  and  is  easily  picked  up  by  the  instruments, 
and  the  transference  of  many  particles  of  hair  into  the  wound 
is  distinctly  to  be  avoided.  Macintosh  sheets  should  form 
the  only  material  with  which  it  is  possible  for  the  fing-ers  or 
the  instruments  to  come  in  contact. 

In  the  most  convenient  place  below  the  site  of  the  opera- 
tion two  or  more  large  coarse  sponges  should  be  wedged,  so 
as  to  absorb  any  blood  which  may  gravitate  from  the  wound. 
They  should  be  changed  as  often  as  required.  In  the  case  of 
an  excision  of  the  breast,  for  example,  the  sponges  may  be 
wedged  under  the  posterior  margin  of  the  axiUa,  and  between 
the  thorax  and  the  macintosh  covering  the  table.  In  the 
case  of  an  operation  for  hernia  or  a  castration  they  should  be 
placed  against  the  perineum.  By  adopting  this  plan,  blood 
cannot  trickle  beneath  the  patient's  back  or  limbs,  and  much 
time  is  saved,  on  the  completion  of  the  operation,  which 
would  otherwise  be  taken  up  in  cleaning  the  dependent  parts 
of  the  body. 


50  OPERATIVE    SURGERY. 

Every  detail  shonld  be  arranged  as  tidily,  as  clearly,  and 
as  metliodicall}'  as  possible. 

Each  instrument  should  have  its  pro|)er  place  in,  the 
instrument  tray.  The  operator  should  not  rinse  his  hands  in 
the  solution  contained  in  the  tray,  nor  dip  sponges  in  it.  If 
common  care  be  not  exercised,  it  is  possible  for  the  solution 
to  become  so  opaque  that  the  instruments  cannot  be  readily 
identified.  I  have  observed  an  instance  where  a  tumour 
which  had  been  removed  was  placed,  in  a  fit  of  absence  of 
mind  and  in  the  hurry  of  the  operation,  in  the  instrument 
tray,  "svith  the  result  that  the  pressure  and  artery  forceps, 
which  were  at  once  required,  were  rendered  invisible. 

A  basin  containing  warm  carbolised  water  should  be 
placed  on  the  instrument  table,  so  that  the  surgeon  can 
(deanse  his  hands  rapidly  fi'om  time  to  time. 

The  wiping  of  blood-stained  hands  upon  a  dry  towel  is 
neither  an  easy  nor  a  satisfactory  method  of  cleaning  them. 

The  assistant  should  take  every  care  that  all  blood  issuing 
from  the  wound  is  sponged  up  at  once.  If  this  be  not  done, 
blood  may  cover  everything,  and  may  be  carried  about  by 
one  and  another  over  the  whole  field  of  the  operation.  Small 
instruments,  moreover,  may  be  lost  among  the  clots  which 
accumulate  below  the  wound,  and  the  necessary  manipula- 
tions of  the  operator  are  carried  on  in  an  atmosphere  of 
.sticky  uncleanness.  An  active  assistant  may  make  any 
ordinary  operation  appear  almost  bloodless,  and  his  efforts 
will  not  end  with  appearances  merely,  but  will  conduce  to 
that  precise  cleanliness  which  is  so  essential  about  an  opera- 
ting table,  and  to  that  "  clear  field  "  which  is  so  much  prized 
by  the  neat  operator. 

As  each  instrument  is  used,  it  should  be  returned  at  once 
to  its  proper  place  in  the  tray.  There  is  a  disposition  to  leave 
the  instnimcnts  lying  about  on  the  operating  table,  on  the 
macintosh,  and  on  convenient  parts  of  the  patient's  body. 
This  slovenly  habit  renders  it  possible  for  the  operation  to 
be  stopped  while  the  surgeon  and  his  assistants  are  hunt- 
ing for  lost  forceps  among  the  folds  of  the  |)atient's  clothing 
or  Vjcnoath  his  limbs. 

The  Making  of  the  Wound. — The  question  of  the  precise 
manner  in   which  the   scalpel    or   knife   should   be  hclii   in 


THE    MAKING    OF    THE     WOUND. 


Fig.  11. 


making  an  incision  must  be  left  to  a  great  extent  to  the  taste 

and  custom  of  the  indivifhial  operator.    In  making  the  Ughtest 

and .  finest  incisions,   as  in 

exposing  an  artery  and  in 

some     [)lastic     operations, 

it  is  well  that  the  scalpel 

should    be    held     between 

the       thumb       and       the 

fingers    like    a     pen,    the 

thickest  part  of  the  handle  being  the  part  grasped  (Fig.  11). 

If  more  power  be  required,  the  scalpel  may  be  held  some- 
what as  a  violin  bow  is  held,  in  the  position  shown  in  Fig.  12. 

"  This  method,"  as  Fergusson  observes,  "  requires  great 
steadiness  naturally,  but  with  practice,  much  ease,  elegance, 
and  dexterity  may  be  displayed  when  the  loiife  is  thus  held, 
and  even  the  most  minute  dissections  may  be  effected  with 
the  hand  and  scalpel  in  the  attitude  here  represented." 

In  the  making  of  cuts 
requiring  still  more  power, 
as  in  the  making  of  ordi- 
nary skin  incisions,  and  in 

the    handlLnsr    of     instru-     -r-~::^^^^^z~i7^'^^  -^  ,'rfa^^P^ 
ments  larger  than  the  scal- 
pel, the  knife  may  be  held 
in  the  manner  of  a  dinner  knife,  with   the   forefinger  upon 
the  back  of  the  blade  (Fig.  13). 

In  operating,  the  fact  should  never  be  lost  sight  of  that 
the  best  wound  to  heal  is  a  clean  incised  one,  and  that  a 
lacerated  or  contused  wound  is  a  blemish  on  the  work  of  the 
operator. 

It  is  important  also  to  bear  in  mind  that  the  usual 
operation  wound  is  not  limited  to  the  skin;  it  extends 
into  the  depths  of 
the  part  operated 
upon.  The  wound 
should  be  an  in- 
cised one,  whenever 
possible,  throughout 
its  whole  extent.  The  skin  may  have  been  divided  by  a 
clean  cut,  while  the  deeper  tissues  may  have  been  severed  by 

E  2 


Fig.  12. 


52  OPERATIVE    SURGERY. 

needless  tearing  and  laceration.  Defects  in  healing  are  more 
often  met  with  in  the  depths  of  a  wound  than  in  the  integu- 
mentary part  of  it. 

Each  cut  should  be  made  cleanly  and  precisel}'-,  and  Avith 
as  much  care  and  deliberateness  as  an  engraver  would  bestow 
upon  each  movement  of  his  tool.  In  a  skin  incision  the 
wound  should  be  as  complete  at  its  two  extremities  as  at  its 
centre.  It  should  be  of  even  depth  throughout,  be  well 
finished,  and  present  no  "  tails." 

The  depths  of  the  wound  should  not  be  torn  open  with  the 
fingers.  The  fingers  are  useful  enough  and  necessary  enough 
in  opening  up  the  depths  of  some  operation  wounds,  espe- 
cially when  ligaturing  arteries.  The  fingers  answer  perfectly 
for  separating  some  muscles,  as  in  exposing  the  anterior 
tibial  artery ;  but,  while  inter-muscular  spaces  are  con- 
veniently opened  up  with  the  fingers,  muscle  tissue  should 
never  be  torn  through  by  them.  Many  tumours  are  enu- 
cleated almost  by  the  fingers  alone  ;  but,  in  general  terms, 
it  may  be  said  that  the  more  that  is  done  with  the  scalpel 
and  forceps  the  better. 

There  is  a  great  disposition  towards  the  needless  and 
reckless  use  of  the  "handle  of  the  scalpel."  Those  who 
would  employ  this  means  in  such  an  operation  as  the  ex- 
posure of  an  artery  would  incise  the  skin  in  the  usual  way,  and 
would  then  attempt  the  rest  of  the  operation  (so  far  as  the 
reaching  of  the  vessel  is  concerned)  with  the  forceps,  the 
fingers,  and  the  handle  of  the  scalpel.  A  moderate  use  of 
both  finger  and  handle  of  scalpel  is  well  enough,  especially 
when  a  search  for  a  deep  artery  is  being  made,  but  the 
moderation  must  be  within  the  narrowest  limits. 

A  perfectly  needless  degree  of  injury  may  be  inflicted  upon 
the  tissues  by  this  uncouth  method  of  operating;  parts  are  lacer- 
ated and  displaced,  and  the  anatomical  details  of  the  region 
are  rendered  obscure.  It  is  a  method  which  finds  favour  alone 
with  those  who  use  a  scalpel  with  fear  and  with  unsteady 
hands,  or  who  have  but  a  confused  idea  of  the  topography 
of  the  district  which  they  are  so  roughly  invading. 

The  tearing  of  the  tissues  between  two  pair i<  of  dissecting 
forceps  is  still  more  reprehensible.  It  is,  perhaps,  not  un- 
common in  operating  upon  hernia  to  make  an  incision  to 


TJfE    MAKING    OF    THE    WOUND.  53 

a  certain  depth,  and  then  attempt  to  remove  the  coverings 
of  the  sac  by  jncking  up  layer  after  layer  and  tearing  them 
through  between  two  pairs  of  forceps.  The  operator  who 
exposes  a  sac  by  this  method,  and  Avho  occasionally  aids 
the  "  dissection "  by  the  vigorous  use  of  his  forefinger,  may 
rest  assured  that  there  is  no  worse  way  of  operating,  nor  one 
more  uncertain,  nor — within  reasonable  limits — more  danger- 
ous. 

There  remains,  however,  one  method  of  extending  an 
operation  wound  which  yields  to  none  in  intrinsic  badness. 
It  is  the  method  represented  by  the  use  of  the  director. 
This  sturdy  and  dangerous  piece  of  steel  may  be  employed 
in  two  ways.  The  first  plan  may  be  illustrated  by  the 
operation  of  ligaturing  the  common  carotid  artery.  The 
skin  and  the  subcutaneous  tissues,  with  the  platysma,  are 
divided,  and  the  anterior  edge  of  the  sterno-mastoid  is 
possibly  exposed.  The  surgeon  now  thrusts  a  forefinger 
into  the  wound  and  enlarges  it — Avith  the  utmost  rij^ugh- 
ness — by  tearing.  He  now  puts  aside  the  scalpel,  and  pro- 
ceeds to  expose  the  artery  with  the  dissecting  forceps  in 
one  hand  and  the  sharp-pointed  steel  director  in  the  other. 
This  method  may  be  called  dissecting  by  tearing.  The 
director  when  so  employed  is  infinitely  more  dangerous  than 
the  handle  of  the  scalpel.  Tracts  of  connective  tissue  are 
opened  up  by  its  point ;  veins  may  be  penetrated  or  torn  ; 
nerves  and  other  delicate  structures  are  heedlessly  bruised. 

Great  force  has  to  be  employed,  and  a  wound  of  the  least 
desirable  character  is  produced.  In  ligaturing  such  an  artery 
as  the  external  iliac,  the  director  becomes  peculiarly  dangerous, 
and  recorded  cases  show  that  in  that  operation  it  has  not 
infrequently  been  forced  through  the  peritoneum. 

This  barbarous  procedure  compares  forcibly  with  the  right 
method  of  operating,  in  which  the  whole  wound  represents 
a  clean  incised  cut  from  its  surface  to  its  deepest  part.  Each 
layer  of  tissue  has  been  neatly  divided,  every  step  of  the 
operation  has  been  certain  and  precise,  every  anatomical 
feature  has  been  recognised,  and  the  sheath  of  the  artery 
has  received  the  least  possible  amount  of  hurt. 

The  second  method  of  using  the  director  may  be  illus- 
trated by  the  operation  for  hernia  or  by  lumbar  colotomy. 


54  OPEEATIVE    SURGERY. 

The  skin  incision  is  made,  and  the  director  is  at  once  taken 
in  hand.  A  hole  is  made  in  tke  tissues,  and  into  this  the 
crude  piece  of  steel  is  thrust.  The  tissues  which  cover  in 
tke  director  are  then  hacked  through  with  the  scalpel. 
Another  hole  is  made,  or  the  director  is  thrust  boldty  into 
the  depths  of  the  incision,  and  another  layer  of  tissue  is  left 
mangled.  In  this  way  the  sac  of  a  hernia  is  exposed,  and 
a  tract  of  needlessly  bruised  and  lacerated  tissue  is  left 
beliind. 

The  director  may  be  thrust  into  the  distended  and 
softened  bowel,  or  the  bowel  may  overlap  the  margin  of 
the  dhector,  and  so  be  sliced  open  by  the  knife.  The 
essential  feature  of  the  method  is  that  the  steps  of  the 
operation  are  undertaken  by  the  director,  and  that  the 
scalpel  plays  a  subsidiary  part. 

In  performing  colotomy  with  a  director,  the  separate  layers 
of  fascia  and  of  muscle  are  taken  up  by  this  precious  instru- 
ment, and  divided  upon  it.  As  often  as  not,  the  director 
breaks  through  the  layer  of  muscle  which  it  is  exposing, 
and  so  the  operator  is  spared  the  use  of  the  knife.  The 
resulting  wound  is  a  deep  hole  bounded  by  mangled  tissues. 

The  art  of  operative  surgery  would  benefit  greatly  if  the 
director  were  to  be  entirely  banished  from  the  list  of  surgical 
instruments.  A  dhector  is  certainly  of  service  in  operating 
upon  fistula,  in  dealing  with  sinuses,  in  disposing  of  some 
false  membranes  about  the  viscera,  and  in  herniotomy.  In 
the  latter  operation,  however,  it  is  used  only  when  the  stricture 
is  being  divided,  and  serves  to  save  the  bowel  fi'om  the  undue 
pressure  of  the  finger.  A  surgeon  Avho  cannot  cut  down  upon 
an  artery,  or  expose  a  hernial  sac  or  a  subcutaneous  cyst, 
or  who  cannot  reach  the  transversahs  fascia  in  the  loin  without 
the  use  of  a  director,  had  better  abandon  operating.  The 
liberal  employment  of  a  director  is  a  demonstration  of  in- 
efficiency, and  the  long  list  of  special  directors  is  not  credit- 
able to  surgical  progress. 

In  exposing  a  deep  part,  such  as  the  sac  of  the  hernia, 
the  whole  process  should  be  effected  by  clean  incisions.  The 
knif(!  should  foUow  the  same  ])recise  line,  and  be  carried 
neatly  from  one  end  of  the  wound  to  the  other. 

The  layer  of  tissue  next  to  be  divided  should  be  carefully 


TEE    MAKING    OF    THE    WOUND.  55 

picked  up  with  the  forceps,  and  the  piece  so  held  may  be 
gently  moved  from  side  to  side,  in  order  that  its  density, 
its  thickness,  and  its  freedom  from  deeper  connections  may 
be  made  out.  Now  and  then,  in  approaching  a  hernial  sac, 
the  tissues  may  be  pinched  up  between  the  finger  and  the 
thumb,  so  that  the  thickness  of  the  remaining  layers  may 
be  estimated,  and  the  position  of  the  contained  bowel  or 
omentum  defined. 

It  is  desirable  also  that  the  margin  of  the  wound  should 
not  be  bruised  or  damaged  by  uncouth  retractors.     The  simple 


.sw'!'^        ^''' 


Fig.    14. — MODE  OF  EXPOSING  A  TUMOUR   BY   LIGATURE  OK  THREAD  KETRACTORS. 

wound -hooks,  and  the  wound  -  retractors  described  already 
(page  40)  effect  the  least  disturbance  ol  the  divided  tissues 
and  the  least  encroachment  upon  the  field  of  the  operation. 
Retractors  of  all  kinds,  however,  must  be  used  with  a  light 
hand. 

In  performing  many  small  operations  I  make  use  of  what 
may  be  termed  ligature  retractors.  After  the  incision  through 
the  skin  and  the  subcutaneous  tissues  and  fasciae  has  been 
made,  the  margins  of  the  wound  are  held  aside  by  means  of 
silk  ligatures,  which  are  inserted  close  to  the  cut  edge  on 
each  side  (Fig.  14). 


56  OPERATIVE    SUliGERY. 

These  ligatures  occupy  no  room,  interfere  in  no  way  with 
the  surgeon's  movenieuts,  and  do  not  encroach  upon  the  field 
of  operation.  They  should  be  of  considerable  length,  so  that 
the  assistant  who  holds  them  maj-  be  well  out  of  the  way. 
When  they  are  employed  upon  a  limb,  one  of  the  threads 
may  be  passed  under  the  limb,  so  that  one  assistant  can 
hold  both  threads  upon  the  same  side  of  the  extremity. 

These  retractors  are  very  useful  in  any  operation  for  the 
removal  of  superficial  tumours,  e.g.,  in  dissecting  out  a 
diseased  bursa  patellae.  The  edges  of  the  wound  can  be 
kept  separated  to  the  utmost  extent  throughout  the  opera- 
tion. In  performing  the  radical  cure  for  varicocele,  also, 
no  better  means  can  be  found  of  retracting  the  scrotal 
tissues,  Avhile  the  veins  are  being  exposed,  than  is  afforded 
by  these  threads.  In  such  an  operation  as  that  required 
for  the  Hgature  of  the  lingual  arter}^  the  edges  of  the  wound 
can  be  admirably  separated  by  silk  retractors,  which  have 
the  merit  of  never  slipping,  and  of  occupying  no  appreciable 
space. 

In  performing  some  operations  which  involve  wounds  of 
considerable  depth,  I  have  sometimes  found  it  convenient 
to  attach  a  long  ligature  thread  to  a  deep  fascia  which  has 
been  divided,  but  which  needs  to  be  held  aside.  A  long 
thread  so  applied  in  the  depths  of  a  wound  (and  it  needs 
to  be  applied  by  a  curved  needle  in  a  holder)  often  proves 
the  most  efficient  possible  retractor. 

It  is  desirable  also  in  all  cases  that  the  incision  should  be 
long  enough  for  the  purposes  of  the  operation.  The  attempt 
to  evacuate  a  tumour  through  the  smallest  possible  incision 
often  involves  a  considerable  bruising  and  laceration  of  the 
edges  of  the  wound  in  the  attempt  to  drag  or  squeeze  the 
mass  through  the  narrow  opening. 

A  long,  cleanly  incised  wound  is  always  to  be  preferred 
to  a  shorter  wound  with  contused  margins. 

Surgeons  who  boast  of  the  smallnoss  of  their  incisions 
are  proud  of  what  is  at  most  but  a  questionable  feat.  While 
it  is  most  essential  that  a  wound  should  never  be  larger 
than  is  necessary,  at  the  same  time  it  is  important  that  the 
operator  should  have  a  good  view  of  the  parts  with  which 
he  is  dealing.     There  can  be  no  possible  object  in  attempting 


THE    ARREST    OF   BLEEDING.  67 

to  ligature  the  common  carotid  through  an  incision  an  inch 
long.  It  can  be  done  as  a  feat ;  as  a  surgical  procedure  it 
involves  nuich  cutting  in  the  dark,  and  adds  a  quite  un- 
necessary danger  to  the  operation. 

In  performing  operations  upon  the  abdomen  especially 
is  it  desirable  that  the  parts  to  be  dealt  with  should  be 
well  exposed ;  and  to  attempt  to  gauge  the  manipulative 
skill  of  an  operator  by  the  smalhiess  of  his  laparotomy 
wound  is  often  to  attempt  a  criticism  upon  false  premisses. 

The  Arrest  of  Bleeding. — The  sponging  of  the  wound 
requires  a  little  care.  The  sponge  should  be  as  well  wrung 
out  as  possible,  and  should  be  applied  to  the  surface  with 
a  quick,  firm,  decisive  touch.  There  should  be  no  patting 
of  the  wound,  nor  should  the  sponge  be  roughly  rubbed 
over  it,  or  swept  heavily  across  it.  Hough  sponging  cannot 
do  other  than  injury  to  the  raw  tissues,  besides  being  in- 
efficient and  involving  waste  of  time. 

The  bleeding  surface  should  be  well  exposed,  and  bleeding 
points  should  be  seized  with  the  pressure  forceps  as  soon 
as  they  are  detected.  It  is  needless  to  say  that  the  larger 
vessels  should  be  secured  first.  Pressure  forceps  are  of 
necessity  used  in  haste  as  a  rule,  but  every  care  should  be 
taken  to  grasp  the  vessel  neatly  and  completely,  and  to 
include  no  more  tissue  than  is  absolutely  necessary  between 
the  blades  of  the  forceps. 

To  grasp  a  large  mass  of  tissue  about  a  bleeding  point, 
and  to  allow  the  forceps  to  compress  it  A\dth  the  full  force  of 
the  spring  during  any  considerable  period  of  time,  is  obviously 
bad.  The  structures  so  dealt  with  are  needlessly  crushed ; 
and  it  may  be  no  matter  of  surprise  if  they  sometimes 
slough.  If  in  the  hurry  inciddtal  to  copious  haemorrhage 
the  tissues  are  somewhat  recklessly  seized,  the  forceps 
should  be  readjusted  with  more  care  when  the  urgency  is 
over. 

Simple  oozing  will  usually  yield  to  mere  exposure  to 
the  air,  to  the  effect  of  a  few  seconds  of  time,  to  the 
pressure  of  a  nearly  dry  sponge,  or  to  the  action  of  ice 
or  of  hot  water. 

Small  vessels  need  only  the  treatment  involved  by  the 
continued   pressure   of  the   forceps.      The   longer   they   can 


58  OPEEATIVE    SUBGEBY. 

be  left   on,   the   better,  and   if  then  carefully  removed,  the 
artery  will  usually  be  found  to  have  ceased  to  bleed. 

Thus,  in  excision  of  the  breast  it  is  seldom  found  necessary 
to  ligature  any  vessels.  Continued  pressure  suffices  to  close 
all  such  as  are  not  of  fair  size.  It  will  be  found  in  performing 
an  amputation  that  by  the  time  the  large  arteries  have  been 
secured  and  the  flaps  cleaned  up,  the  pressure  which  has  all 
the  time  been  kept  up  on  the  lesser  vessels  has  sufficed  to 
occlude  them. 

Vessels  a  Httle  larger  than  those  alluded  to  may  usually 
be  dealt  with  by  torsion.  No  especial  torsion  forceps  are  re- 
quired. If  the  artery  has  been  neatly  and  cleanly  picked  up 
by  the  point  of  the  pressure  forceps,  it  can  be  occluded  by 
torsion  ■\\dthout  removing  the  forceps.  The  vessel  should  be 
drawn  weU  out,  and  the  instrument  then  twisted  round  three 
or  four  times  between  the  fingers  and  thumb,  until  there  is  a 
sense  of  lack  of  resistance. 

In  deahng  with  the  larger  arteries,  and  with  main  vessels, 
a  catgut  hgature  must  be  used.  The  vessel,  while  yet  the 
pressure  forceps  occlude  it,  should  be  gently  isolated,  and 
should  then  be  grasped  by  a  pair  of  artery  forceps  (as  the 
first  instrument  is  removed)  and  securely  ligatured. 

In  the  case  of  free  bleeding  from  one  or  more  points 
upon  a  surface,  continued  pressure — to  be  maintained  in 
the  subsequent  dressing  of  the  case — is  the  simplest  mea- 
sure. 

In  instances  in  which  such  pressure  cannot  be  appHed,  the 
bleeding  point  may  be  picked  up  with  a  tenaculum,  and  then 
secured  by  silkworm  gut.  This  thread  is  the  material  that 
of  all  others  is  most  likely  to  retain  a  hold  of  the  tissues  under 
these  conditions.  The  gut  should  be  apphed  in  the  manner 
described  in  speaking  of  sutures  (page  44) :  it  should  not  be 
tied  in  a  knot. 

It  should  be  an  element  m  the  dressing  of  operation  cases 
that  substantial  pressure  is  kept  up  in  order  to  control  any 
continued  disposition  to  bleed. 

The  Closure  of  the  Wound. — In  previous  sections  the 
question  of  the  selection  of  a  suture  material  and  of  suture 
needles  is  dealt  with,  and  the  manner  in  which  sutures  of 
silkworm  gut  arp-  to  be  secured  is  described  (page  43).     This 


THE    CLOSURE    OF    THE    WOUND.  59 

material  may  be  used  in  closing  all  operation  wounds,  with 
very  few  exceptions. 

13et'ore  introducing  the  sutures,  the  wound  should  be  most 
carefully  cleaned,  and  its  edges  accurately  approximated.  It 
is  most  desirable  that  the  margins  of  the  wound  should  be 
well  defined,  and  that  in  uniting  it  parts  which  were  in 
contact  before  the  operation  should  be  once  more  brought 
into  aj^position.  As  the  tissues  left  after  the  lemoval  of  a 
tumour  or  the  reduction  of  a  large  hernia  are  lax,  and  the 
integument  is  flabby  and  in  folds,  it  is  easy  for  the  wound 
to  be  irregularly  united  and  to  be  puckered  in  one  place,  and 
too  tightly  drawn  in  another. 

In  all  but  the  smallest  incisions,  therefore,  the  edges  of  the 
wound  should  be  put  upon  the  stretch,  and  be  so  adjusted  to 
one  another  that  they  form  when  in  contact  a  simple  line. 
This  is  effected  by  introducing  a  large  blunt  hook  into  each 
angle  of  the  wound  in  the  manner  shown  (Fig.  15),  and  by 


fig.  15. — method  of  steadying  the  iiargi-vci  of  a  wound  with  blunt  hooks 
di:ring  the  introddction  of  the  SUTDRES. 


then  drawing  upon  the  hooks  until  the  wound  margins  are 
parallel  and  are  approximated  to  one  another.  The  hooks 
should  be  of  good  size,  and  I  have  found  that  the  most 
convenient  curve  is  that  of  half  of  a  circle  with  a  diameter 
of  three-quarters  of  an  inch. 

The  needle  should  be  introduced  as  close  to  the  free  edge 
of  the  wound  as  is  consistent  mth  a  good  hold  upon  the 
tissues.  If  the  suture  be  applied  too  near,  the  hold  obtained 
is  slender  and  tli(^  thread  is  apt  to  cut  through.  If  it  be 
inserted  at  too  great  a  distance  from  the  wound,  the  margins 
of  the  incision  are  liable  to  become  turned  in  upon  one 
another. 

In  closing  large  Avounds,  and  in  inserting  sutures  which 


60  OPERATIVE    SURGERY. 

will  be  exposed  to  strain  (as  in  wounds  of  the  abdomen, 
deep  wounds  of  fleshy  parts,  and  amputation  flaps),  it  is 
well  to  place  the  main  sutures  at  some  distance  apart  (about 
three-fourths  of  an  inch),  and  some  way  (about  three-eighths 
of  an  inch)  from  the  edge  of  the  wound.  A  very  good  hold  is 
thus  obtained  upon  the  tissues.  Between  these  main  sutures 
smaller  secondary  sutures  are  inserted,  which  are  introduced 
close  to  the  margin  of  the  wound. 

In  subsequent  paragraphs  special  details  are  given  as  to 
the  method  of  closing  particular  incisions  {vide  Abdominal 
Section,  etc.). 

Sutures  are  probably  more  often  drawn  too  tightly  than 
tied  too  lightly. 

In  using  silk  the  knot  should  be  so  placed  as  not  to  press 
upon  the  skin  at  the  needle  aperture. 

The  sutures  described  unite  merely  the  skin-cut,  and  it 
must  be  remembered  that  in  an  operation  incision  this  skin- 
wound  forms  the  least  part  of  the  lesion.  The  main  wound, 
represented  by  two  large  raw  surfaces,  lies  beneath  the  integu- 
ment. Although  the  sutures  may  close  the  cut  in  the  skin 
efficiently,  they  may  leave  the  depths  of  the  wound  unaffected, 
and  while  the  minor  surface  incision  is  perfectly  adjusted,  the 
great  wound,  which  spreads  deep  into  the  tissues,  remains 
gapmg.  The  union  of  the  skin,  indeed,  may  convert  the  latter 
into  a  cavity  with  raw  and  flaccid  walls,  which  are  at  no  place 
in  contact  with  one  another.  Here,  then,  is  an  actual  evil 
— the  production  of  a  large  subcutaneous  cavity  in  which 
accumulations  can  readily  occur  and  decomposition  take 
place. 

In  placing  the  parts  in  the  best  position  for  healing,  the 
union  of  the  severed  tissues  beneath  the  surface  and  the 
obliteration  of  the  wou/nd  cavity  become  matters  of  the  first 
importance.  It  is  with  the  greater  lesion  the  surgeon  should 
concern  himself,  rather  than  with  the  mere  cut  in  the  skin. 
A  little  experience  wiU  soon  enforce  the  fact  that  the  mere 
hiding  of  the  depths  of  the  wound  by  sewing  up  the  rent 
in  the  integument  does  not  constitute  a  closure  of  the  breach. 
The  cutaneous  wound  after  it  has  been  closed  will,  as  a  rule, 
heal  kindly  enough. 

If,  on  the  other  hand,  there  be  any  defect  in  the  healing, 


THE    CLOSURE    OF    THE    WOUND.  61 

it  usually  proceeds  from  the  depths  of  the  incision.  When  a 
wound  "  breaks  do^vn,"  the  breaking  down  most  commonly 
starts  in  the  deep  woimd,  and  not  in  that  in  the  integument. 
The  chief  local  troubles  attending  large  incisions  concern  the 
subcutaneous  part  of  the  lesion,  and  take  such  forms  as  the 
accumulation  of  blood,  the  bagging  of  pus,  the  formation  of 
sinuses,  the  spreading  of  inflammation  into  the  adjacent 
cellular  tissue,  and  the  hke. 

To  ensure  the  best  possible  adjustment  of  the  whole  sur- 
face of  the  wound  and  the  obhteration  of  what  is  conveniently 
termed  the  wound  cavity,  the  following  method  should  be 
adopted.  It  may  be  illustrated  by  a  case  of  excision  of  the 
breast: — All  haimorrhage  has  been  checked,  and  the  whole 
surface  of  the  wide-open  wound  has  been  freed  from  blood-clot 
and  from  fragments  of  tissue,  and  has  been  well  cleansed  by 
a  stream  of  carbolised  lotion  which  has  been  allowed  to  run 
over  it  from  an  irrigator.  The  wound-surface  has  not  been 
scrubbed  clean  with  a  sponge,  as  is  a  common  practice.  A 
sponge  so  applied  inflicts  a  quite  needless  damage  upon  the 
already  injured  tissues,  and  may  cause  an  occluded  blood- 
vessel to  start  bleeding  again. 

The  margins  of  the  wound  are  now  approximated,  and 
rendered  parallel  and  tense  by  means  of  the  two  blunt  hooks, 
and  the  sutures  are  introduced,  one  by  one,  commencing  at 
the  highest  part  of  the  wound.  The  sutures  are  not  tied  at 
first,  but  are  merely  introduced  through  the  tissues.  They 
may  be  so  inserted  throughout  the  whole  length  of  the 
wound,  or,  as  is  more  convenient,  through  the  upper  or  least 
dependent  part  of  it  only  at  first.  Before  these  sutures  are 
secured  and  the  first  part  of  the  incision  closed,  the  corre- 
sponding deep  part  of  the  wound  should  be  again  cleaned  out 
with  the  irrigator  or  dried  with  the  sponge ;  and  as  the 
surgeon  ties  each  suture  an  assistant  gently  wipes  the  edges 
of  the  wound  for  the  last  time,  and  then  with  a  large  sponge 
compresses  firmly  all  such  part  of  the  cut  as  has  been  closed 
up.  This  pressure  should  never  be  relaxed.  Li  the  case  of 
an  excision  of  the  breast,  it  at  once  compresses  the  integu- 
ments against  the  thorax,  brings  the  deep  surfaces  of  the 
wound  well  together,  and  quite  obliterates  the  cavity  of  the 
wound.     Any   further   tendency   to  oozing   is   checked,   and 


62  OPERATIVE  SURGERY. 

there  is  no   space   possible   in   which   an  exudation   should 
collect. 

The  pressure  closes  the  breach,  and  the  assistant  must 
take  care  that  it  is  never  for  a  moment  relaxed. 

FoUoAving  the  same  method,  the  surgeon  closes  in  the  rest 
of  the  wound,  dealing  with  the  most  dependent  part  last. 
Before  he  ties  a  suture  he  satisfies  himself  that  the  corre- 
sponding depths  of  the  wound  are  clean  and  practically  dry. 
As  he  closes  the  skin  wound,  inch  by  inch,  the  assistant  with 
the  pressure-bearing  sponge  follows  his  hands  ;  the  wound 
cavity  is  thus  gradually  and  certainly  obliterated,  and  will 
remain  so  as  long  as  the  compression  is  maim  .lined.  A 
drainage  tube  is  very  often  not  needed,  because  there  is  little 
or  no  space  to  drain,  and  if  a  small  gap  is  left  between  the 
sutures  at  the  most  dependent  part  of  the  wound  a  safety 
valve  is  provided  in  case  of  any  accident.  Without  relaxing 
the  pressure  kept  up  upon  the  wound,  the  sponges  are  cau- 
tiously and  gradually  replaced  by  the  dressing  to  be  employed. 
This  will  probably  consist  of  a  sponge  or  sponges  well  dusted 
with  iodoform  and  a  very  large  quantity  of  absorbent  avooI. 
The  patient's  arm  is  now  carried  right  across  the  wound,  the 
hand  of  the  injured  side  restmg  upon  the  opposite  shoulder, 
and  in  this  position  the  limb  is  very  firmly  secured  in  the 
manner  to  be  afterwards  described,  and  is  made  to  act  the 
part  of  a  compressing  splint.  The  wound  cavity  is  practically 
obliterated  by  pressure,  and  that  pressure  should  be  main- 
tained until  the  wound  has  healed. 

This  method  can  be  applied  to  almost  any  deep  wound, 
and  even  to  incisions  involving  the  neck.  The  principle  re- 
mains unchanged  although  the  'modus  operandi  may  vary. 

In  the  case  of  amputations,  a  hke  pressure,  very  cautiously 
and  discreetly  applied,  serves  to  keep  the  raw  surfaces  of 
flaps  in  perfect  apposition,  to  obliterate  any  space  which  may 
exist  between  them,  to  prevent  any  after  oozing  of  blood,  and 
to  allow  no  cavity  to  exist  in  which  an  accumulation  could 
take  place.  Under  this  method  Avounds  heal  admirably,  and 
I  venture  to  think  that  it  reduces  the  complications  of  wounds 
to  the  smallest  limits. 

The  surgeon  must  exercise  some  ingenuity  in  devising  the 
best  method  of  applying  pressure  in  each  particular  case  ;  he 


TllL'    CLOSURE    OF    THE    WOUND.  63 

must  make  use  of  it  with  discretion,  and  must  recognise  the 
possibility  of  its  being  unsuited  in  some  local  conditions. 

Some  operators  have  advised  the  use  of  deep  or  buried 
sutures,  and  have  claimed  that  the  deeply-placed  wound  sur- 
faces are  thereby  as  effectually  brought  together  as  are  the 
margins  of  the  skin  incision.  They  advise,  moreover — 
especially  in  the  adjusting  of  amputation  flaps — that  severed 
parts  should  be  united  by  suture  like  to  like — i.e.,  muscle  to 
muscle,  fascia  to  fascia,  aponeurosis  to  aponeurosis. 

In  the  case  of  a  deep  wound  in  which  important  structures 
have  been  divided,  such  as  tendons  and  dense  fasciae,  it 
may  be  desirable — in  obedience  to  a  rudimentary  principle  in 
surgery — to  specially  unite  the  severed  tissues  with  sutures. 
Such  a  proceeding  would,  however,  be  of  quite  limited  ap- 
plication, and  the  needs  for  it  may  be  considered  to  be  acci- 
dental. It  has  not  been  shown  by  those  who  unite  flaps  by  a 
number  of  so-called  buried  sutiu-es  that  the  method  possesses 
any  detinite  advantage  in  actual  practice. 

The  objections  to  be  urged  against  deep  sutures  generally 
are  the  following  : — 

Their  application  involves  time  and  prolongs  the  opera- 
tion. The  tissues  are  needlessly  disturbed,  and  possibl}' 
damaged,  in  the  application  of  the  sutures.  The  threads 
employed  are  at  best  foreign  substances,  and  the  introduction 
of  ten  or  twenty  unnecessary  fi-agments  of  catgut  into  the 
depths  of  a  wound  is  at  least  undesirable.  Moreover,  the 
buried  sutures  do  not  offer  the  best  means,  either  of  approxi- 
mating the  raw  surfaces  of  a  deep  woimd,  or  of  obliterating 
the  wound  cavity,  and  in  many  notable  examples — such  as 
is  afforded  by  an  excision  of  the  breast — the  application  is 
scarcely  possible. 

The  length  of  time  diu-ing  which  surface  sutures  may  be 
retained  cannot  be  arbitrarily  stated.  Those  of  silk  soon  cause 
irritation,  and  if  not  removed  within  a  certain  time  are  apt  to 
j)roduce  sutural  abscesses.  From  five  to  eight  days  will 
approximately  represent  the  limit  of  time  during  which  such 
sutures  may  with  safety  be  retained. 

With  silkworm  gut,  if  properly  applied,  the  case  is  dif- 
ferent. It  is  exceedingly  uncommon  for  these  sutures  to 
produce    sutural    abscesses,   and    the   irritation    which    they 


64  OPERATIVE    SURGERY. 

excite  is,  in  the  majority  of  cases,  quite  insignificant.  I  have 
often  allowed  silkworm-gut  sutures  to  remain  in  the  woimd 
for  ten  or  fourteen  days,  and  in  the  operation  for  the  closure 
of  a  cleft  palate  they  may  be  left  in  for  three  weeks  if 
necessary.  If  the  ends  be  left  long  enough,  the  suture  can  be 
tightened  or  loosened  while  it  remains  in  situ;  they  are 
readily  removed,  and  leave  very  Httle  evidence  of  theh  pre- 
sence. 

The  almost  exclusive  use  of  this  material  for  the  last 
few  years  in  operation  cases  of  all  kinds  has  led  me  to 
beheve  that  it  forms  the  very  best  substance  for  closing 
wounds  with  which  we  are  acquainted. 

The  Draining  of  the  Wound. — In  many  cases  of  opera- 
tion wounds  no  drainage  tube  of  any  kind  is  required. 
The  great  essential  in  dealing  with  a  wound  is,  as  already 
said,  to  bring  all  parts  of  the  cut  surfaces  together,  and  to 
obliterate  the  wound  cavity.  If  this  be  efficiently  done,  there 
is  no  place  in  which  exudations  can  accumulate,  and  no  area 
to  drain. 

If,  on  the  other  hand,  the  margins  of  the  skin  woimd  are 
very  closely  united  while  the  depths  of  the  incision  are  left 
unheeded,  then  it  will  often  happen  that  a  closed  sub- 
cutaneous cavity  is  left,  into  which  the  discharges  from  the 
divided  tissues  may  flow,  and  from  which  they  have  no  way 
to  escape. 

If  a  cavity  be  quite  unavoidable,  then  a  drainage  tube 
must  be  inserted;  but  if  no  cavity  exist,  then  the  tube 
serves  merely  to  separate  the  cut  surfaces  and  to  impede 
their  proper  union.  The  actual  forcing  asunder  of  the  sur- 
faces of  some  simple  deep  wounds,  such  as  may  be  left  after 
the  hgature  of  an  artery,  appears  to  be  quite  unwarrantable, 
and  to  be  opposed  to  the  simplest  principles  of  surgery. 

The  drainage  tube  has  faUen  into  discredit  mainly  on 
account  of  its  indiscriminate  and  unreasonable  employment  as 
a  routine  feature  in  almost  every  operation  case. 

From  large  wound  surfaces,  such  as  are  left  after  an 
amputation  or  the  removal  of  a  tumour,  a  not  inconsiderable 
oozing  of  blood  and  serum  may  be  expected.  The  escape  of 
this  is  encouraged  by  the  pressure  which  is  maintained  upon 
the  parts,  by  not  introducing  the  sutures  too  closely,  and  by 


THE    DRAINING    OF    THE    WOUND.  65 

leaving  some  gap  between  them  at  the  most  dependent  ])art 
of  the  wound.' 

Should  these  means  appear  inefficient,  then  a  tube  may  be 
inserted  and  removed  in  24  or  48  hours. 

In  many  cases  where  pressure  cannot  be  well  applied — as 
in  some  parts  of  the  neck — and  where  gravity  does  not  aid 
the  escape  of  exudations,  and  where  also  a  neatly  adjusted* 
skin  wound  is  a  matter  of  importance,  a  drain  may  be  in- 
troduced. But  in  such  cases  there  very  rarely  remains  any 
excuse  for  retaining  it  for  more  than  24,  or,  at  the  most,  30 
hours,  after  the  operation. 

These  are  instances  where  a  tube  may  be  serviceable,  and 
the  other  conditions  under  which  it  may  be  employed  with 
advantage  are  such  as  the  following  : — 

(a)  When  a  cavity  is  produced  at  the  bottom  of  which 
tissue  is  exposed  which  could  not  be  expected  to  join  in  a 
normal  healing  process.  This  is  a  condition  met  "V\dth  after 
some  resections  of  bone,  after  some  operations  upon  diseased 
joints,  and  after  the  partial  removal  of  cystic  growths. 

(b)  When  there  is,  or  is  likely  to  be,  a  considerable  oozing 
of  blood,  as  in  incomjjlete  ovariotomies. 

(c)  When  sinuses  or  inflamed  districts  are  opened  up  in 
the  course  of  the  operation,  and  when  the  involved  tissues  are 
allowed  to  remain  in  whole  or  in  part.  This  is  illustrated  by 
an  amputation  for  disease,  where  an  old  sinus  occupies  the 
substance  of  a  flap,  or  the  track  of  a  sinus  is  exposed  in  the 
depth  of  the  stump.  Although  these  sinuses  may  have  been 
well  scraped,  they  can  scarcely  be  expected  to  take  a  whole- 
some part  in  the  healing  process. 

{d)  When  much-damaged  tissues  are  left  in  the  depths  of  a 
wound,  as  in  cases  where  deeply-attached  tumours  have  been 
removed  with  great  difficulty,  and  with  much  bruising  and 
laceration  of  the  soft  parts,  and  the  application  possibly  of 
many  ligatures.  In  such  cases  the  insertion  of  a  drainage 
tube  is  a  wise  precaution. 

(e)  When  an  operation  has  been  performed  upon  an 
oedematous  or  infiltrated  part,  it  is  inevitable  that  much 
oozing  will  occur  during  at  least  the  first  few  days,  and  this 
should  be  allowed  to  escape  fi-eely.  In  a  case  therefore  of 
amputation,  where  the  flaps  are  fonned  out  of  tissues  which 


66  OPERATIVE    SURGERY. 

are  still  oedematous,  a  tube  may  be  employed  to  give  free  vent 
to  the  fluid  which  will  ooze  from  the  cut  surfaces. 

(/)  Drainage  may  be  employed  in  certain  cases  when  the 
wound  is  foul  at  the  time  of  the  operation,  in  some  operations 
near  the  anus,  and  in  instances  where  a  fistula  is  inevitable, 
as  after  certain  operations  upon  the  bowel,  kidney,  etc. 

The  Local  Conditions  which  influence  Primary  Healing. 
— The  circumstances  which  affect  the  future  well-being  of  an 
operation  wound  are  very  numerous.  The  more  general  of 
these  have  been  already  considered,  and  are  such  as  concern 
the  health  of  the  patient,  his  surroundings,  and  the  mag- 
nitude and  duration  of  the  operation. 

The  local  conditions  which  encourage  sound  heahng  by 
first  intention  have  been  also  in  some  way  alluded  to.  They 
may  be  briefly  summarised  as  follows : — 

1.  The  wound  is  a  clean  cut,  and  the  surfaces  of  the 
wound  have  been  neither  lacerated  nor  contused. 

•I.  The  tissues  dealt  Avith  are  healthy,  are  free  from  any 
infiltration,  are  left  well  supplied  with  blood,  and  are  removed 
from  any  source  of  septic  infection. 

3.  The  wound  surfaces  have  not  been  roughly  sponged, 
and  have  not  been  washed  with  too  strong  or  too  irritating 
an  antiseptic  solution. 

4.  There  is  no  tension  upon  the  sutures,  and  they  have 
not  been  applied  too  closely. 

5.  All  haemorrhage  fr-om  the  divided  tissues  has  been 
checked. 

6.  The  edges  of  the  wound  have  been  brought  well  to- 
gether, and  the  wound  cavity  has  been  obliterated  by 
pressure. 


67 


CHAPTER    VI. 

The  After-Treatment  of  the  Wound, 

Immense  progress  has  been  made  of  late  years  in  the 
treatment  of  wounds.  In  this  progress  the  most  prominent 
figure  is  that  of  Sir  Joseph  Lister.  To  him  belongs  the 
honour  of  having  effected  a  reformation  in  surgery,  of  having 
estabHshed  upon  a  new  and  scientific  basis  the  ancient  art 
of  heaKng,  of  having  freed  the  operator  from  the  more 
grievous  of  the  dangers  Avhich  surround  him,  and  of  having 
greatly  extended  the  powers  and  possibilities  of  the  surgeon's 
art. 

As  to  the  exact  method  of  dressing  a  wound,  and  the 
materials  to  be  used  in  that  dressing,  it  is  impossible  to  be 
dogmatic,  or  even  to  be  precise. 

Probably  at  no  time  have  the  modes  of  dealing  with 
wounds  been  more  numerous,  nor  has  the  application  of  a 
few  common  principles  been  more  diverse. 

All  surgeons  endeavour  that  the  wound  shall  be  quite 
clean ;  shall  be  aseptic ;  shall  not  be  irritated ;  shall  be 
kept  at  rest.  One  surgeon  accomplishes  these  ends  in  one 
Avay  and  another  in  another,  and  the  results  are  equal.  He 
who  considers  that  his  method  of  dealing  with  a  wound  is 
the  most  perfect  will  find  that  his  neighbour,  who  adopts  very 
different  details,  obtains  an  identical  measure  of  success. 

New  antiseptic  agents  appear  from  time  to  time  upon  the 
scene.  They  are  pursued,  are  vaunted  as  perfect,  are  dili- 
gently employed,  and  then  not  a  few  of  them  fade  away,  some 
very  gradually,  others  with  the  suddenness  of  the  South  Sea 
Bubble. 

With  these  reservations,  I  might  describe  the  method  of 
dealing  with  operation  wounds  which  has  appeared  to  me  to 
be  satisfactory. 

The  part  must  be  kept  absolutely  at  rest.    Mere  confinement 


68  OPERATIVE    SURGERY. 

in  bed,  with  the  support  of  a  proper  pillow,  may  suffice 
to  eifect  this,  or  a  special  splint  or  retentive  apparatus  may  be 
employed. 

The  part  is  kept  raised,  so  that  the  circulation  of  the 
blood  through  it  may  be  as  much  reheved  as  possible,  and  is 
so  placed  that  the  drainage  of  any  discharges  may  be  readily 
effected. 

The  wound  itself  is  dressed  simply  with  sponges  dusted 
with  iodoform.  These  are  held  in  place  by  much  absorbent 
wool,  over  which,  possibly,  a  layer  of  gauze  is  placed. 

A  bandage  is  then  so  appHed  as  to  bring  pressure  to  bear 
upon  the  "wound.  The  effect  of  this  is  that  the  edges  of  the 
incision  are  kept  well  together,  the  cavity  of  the  wound  is 
obhterated,  any  tendency  to  oozing  is  prevented,  the  use  of  a 
drainage  tube  is  rendered  unnecessary,  and  the  parts  con- 
cerned in  the  wound  are  kept  perfectly  at  rest. 

No  material  keeps  up  a  more  effective  form  of  pressure 
than  a  sponge.  Sponges  so  employed  can,  after  cleaning,  be 
used  over  and  over  again.  There  should  be  a  liberal  covering 
of  wool,  as  it  tends  to  equalise  and  diffuse  the  pressure  em- 
ployed. The  ordinary  carbolic  gauze  answers  the  part  of 
keeping  the  wool  well  in  place,  as  it  adheres  a  little  to  the  skin. 

The  amount  of  pressure  employed  must  depend  upon  the 
circumstances  of  the  individual  case.  Unlimited  pressure 
would  obviously  not  be  employed  in  cases  where  the  vascular 
supply  of  the  part  is  shght  and  the  patient  very  old. 

The  sim]Dler  wounds,  such  as  those  following  abdominal 
section,  the  hgature  of  an  artery,  or  the  removal  of  a  small 
growth,  need  not  be  disturbed  for  a  week.  Such  wounds  as 
result  from  excision  of  the  breast  or  an  uncomphcated  am- 
putation may  be  left  for  three  to  five  days.  If  much  oozing 
be  anticipated,  the  wound  may  be  dressed  at  the  end  of 
twenty-four  hours,  and  then  left  for  four  or  five  days. 

In  the  place  of  the  natural  sponge  the  "  artificial  sponge  " 
answers  fairly  well 

TiUmann's  "dressing  linen"  is  an  admirable  application 
for  wounds.  It  is  soft  and  compressible,  and  very  absorbent, 
and  possesses  the  great  good  quality  of  not  sticking,  to  the 
wound. 

No  stronger  antiseptic  lotion  is  used  than  a  one  in  forty, 


THE    AFTER-TREATMENT.  69 

or  in  some  cases  a  one  in  thirty,  solution  of  pure  carbolic 
acid. 

The  wounded  part  should  be  kept  in  the  open  air — i.e.,  be 
as  far  as  possible  uncovered  by  the  bed-clothes.  This  will  be 
more  or  less  inevitable  with  wounds  of  the  head,  neck,  and 
upper  extremity.  The  lower  limb,  after  operation,  should  be 
quite  uncovered  by  the  bed-clothes.  The  atmosphere  under 
bed-clothes  is  limited,  is  hot,  is  moist,  and  is  frequently  foul, 
as  after  the  use  of  the  bed-pan  or  the  escape  of  flatus.  If 
there  be  any  truth  in  the  prmciples  which  underlie  antiseptic 
surgery,  no  atmosphere  could  be  worse  for  a  wound.  The 
exposed  limb  may  be  wrapped  up  during  the  cold  Aveather, 
and  in  my  wards,  where  no  wound  of  the  extremities  is  ever 
allowed  to  be  covered  by  bed-clothes,  I  have  never  heard  any 
complaint  on  the  ground  of  the  part  bemg  unduly  cold. 
Fresh  wounds,  as  well  as  old  ulcers,  have  healed  with  greater 
readiness  and  certainty  since  I  introduced  this  rule. 

In  operations  about  the  pelvis,  such  as  castration  and  the 
radical  cure  of  varicocele,  the  part  can  be  kept  in  a  reasonably 
healthy  atmosphere  by  a  simple  arrangement  of  the  clothes 
over  a  bed  cradle.  Unless  there  be  some  indication  to  the 
contrary,  the  wounds  resulting  from  these  operations  should  be 
dressed  after  every  action  of  the  bowels. 


71 


part  II. 

THE    ADMINISTRATION    OF 
ANJESTHETICS. 

{This  section  has  been  specially  written  by  Frederic  Wm. 
Hewitt,  M.A.,  M.D.,  Cantab.,  Ancesthetist  to  and  Lecturer 
on  Anaesthetics  at  the  London  Hospital.] 

CHAPTER    I. 

The  Anesthetic  Agents  most  Commonly  Employed  : 
Their  Properties  :  and  the  Effects  which  they 
Produce  when  Administered  to  Normal  Adults. 

1.  ether. 

Properties. — Pure  ether  is  a  colourless,  highly  volatile, 
inflammable  liquid  of  specific  gravity  '720.  The  odour  of  its 
vapour,  although  not  verj^  pleasant,  is  more  agreeable  than 
that  of  the  "  pure  methylated  ether "  often  employed.  The 
latter  drug  produces  greater  irritation  to  the  ah  passages,  is 
required  in  larger  quantities  to  produce  ansesthesia,  and  is 
more  often  followed  by  nausea  and  vomiting  than  the  pure 
€ther  which  should  always  be  employed.  The  vapour  of 
this  anaesthetic  being  inflammable,  care  should  be  taken  not 
to  bring  an  artificial  light  or  a  cautery  near  vessels  con- 
taining ether,  or  near  the  mouth  of  a  patient  who  is  fidly 
under  the  influence  of  ether.  It  must  be  borne  in  mind  that 
the  temperature  of  the  room  in  which  the  administration  is 
being  conducted  materiall}^  influences  the  rapidity  with  which 
•ether  evaporates,  it  being  more  difficult  to  quickly  anaesthetise 
a  patient  with  ether  in  cold  than  in  hot  weather. 

Effects  of  Inhalation. — Assuming   that  ether  va^jour  is 


72  OPERATIVE    SURGERY. 

gradually  given,  the  effects  which  it  produces  will  be  found  to 
be  largely  dependent  upon  the  degree  to  which  air  is  allowed 
to  enter  the  lungs  with  the  vapour.  When  ether  is  adminis- 
tered by  means  of  a  cone  or  towel,  so  that  a  copious  supply 
of  air  is  admitted,  the  anaesthetic  may  be  said  to  be 
administered  by  the  "  open  "  method  ;  when  ether  is  given  in 
such  a  way  that  the  supply  of  air  is  limited,  as  by  using  a 
Clover's  or  Ormsby's  inhaler,  the  "close"  method  results. 
When  ether  is  given  with  a  copious  supply  of  air,  much 
irritation  in  the  upper  air-passages  is  produced ;  the  patient 
frequently  experiences  a  sense  of  suffocation ;  coughing 
occurs  ;  excitement,  gesticulation,  and  struggling  are  common ; 
and  a  considerable  period  may  elapse  before  surgical  anaes- 
thesia is  reached.  Clover  was  the  first  to  demonstrate  the 
advantages  of  the  close  method  of  inhalation  (page  84),  and  if 
the  administration  be  conducted  strictly  in  accordance  with 
his  du'ections,  coughing,  excitement,  and  struggling  will  either 
occur  in  a  very  minor  degree,  or  will  be  wholly  avoided,  anses- 
thesia  becoming  quietly  estabhshed  in  from  two  to  five  minutes. 
When  surgical  ansesthesia  has  been  produced,  it  will  be  found 
that  the  pulse  is  full,  soft,  regular,  and  somewhat  accelerated; 
the  respiration  is  quickened,  and  considerably  deepened; 
deep  snoring  stertor  is  present ;  the  pupils  are  dilated  in 
proportion  to  the  depth  of  etherisation  ;  the  muscular  system 
is  relaxed,  and  reflex  action  for  the  most  part  is  abolished. 
Large  quantities  of  ether  are  sometimes  needed  before  relaxa- 
tion and  loss  of  all  reflex  action  become  established.  There 
are  four  reflexes  to  which  attention  should  be  directed :  viz., 
movements  of  the  extremities  dej)endent  upon  the  surgical 
procedure ;  closure  of  the  eyelid  when  the  conjunctiva  is 
touched  ;  the  act  of  deglutition  evoked  b}^  mucous  or  ether 
vapour  ;  and  cough,  also  the  result  of  the  two  last-named 
stimuli  If  all  these  reflex  phenomena  be  absent,  the  narcosis 
may  be  said  to  be  profound.  If  only  moderate  anesthesia  be 
maintained,  some  of  the  reflex  acts  here  referred  to  will  occur. 
Large  quantities  of  ether  are,  as  a  rule,  necessary  in  operations 
about  the  genito-urinary  organs  and  rectum ;  otherwise 
tranquil  ansesthesia  will  not  be  secured.  The  order  in  which 
reflexes  disappear  will  be  found  to  vary  in  different  subjects. 
Generally  speaking,  however,  the  lid  reflex  is  one  of  the  latest 


CHLOROFORM.  73 

to  disappear,  and  hence  the  earliest  to  reappear  when  the 
administration  is  discontinued.  As  the  patient  tends  to 
"  come  round"  the  lid  reflex  usually  first  manifests  itself;  then 
swallowing  takes  place ;  then  a  cough  is  given,  and  retching 
or  vomiting  often  follows.  Excitement  after  etherisation  is 
imcommon. 

2.  CHLOROFORM. 

Properties. — "  A  limpid,  colourless  liquid,  of  an  agreeable 
ethereal  odour  and  sweet  taste  ;  dissolves  in  alcohol  and  ether 
in  all  proportions  :  specific  gravity  1497  "  (B.  P.).  Care  should 
always  be  taken  to  employ  the  purest  chloroform.  Unlike 
ether,  chloroform  vapour  is  not  inflammable. 

Effects  of  Inhalation. — Chloroform  vapour  is  by  no  means 
unpleasant  to  inhale  when  gradually  administered  with  a 
copious  supply  of  air.  When  thus  given,  chloroform  vapour  is 
far  less  irritatmg  than  that  of  ether,  and  hence  coughing  and 
other  evidences  of  irritation  are  usually  absent.  Some  tinnitus 
and  other  unpleasant  sensations  are  occasioiially  experienced  r 
but,  generally  speaking,  the  patient,  if  not  frightened  by 
surroundings,  or  by  too  strong  a  vapour,  passes  into  a  dreamy 
state,  in  which,  although  consciousness  to  a  great  extent 
remains,  pain  is  not  appreciated.  This  analgesic  effect  of  small 
quantities  of  chloroform  is  taken  advantage  of  during  labour, 
and  as  the  main  element  of  danger  from  chloroform— viz., 
too  strong  a  vapour  and  too  little  air — is  absent,  the  mortality 
under  chloroform  thus  administered  is  practically  nil  As  the 
administration  proceeds,  consciousness  becomes  gradually  de- 
stroyed. There  is  nearly  always  a  period  of  some  excitement 
similar  to  that  produced  by  ether  when  given  by  the  open 
method.  Reflex  action  is  at  this  stage  still  perfect,  so  that  the 
patient  may  move  or  shriek  if  the  operation  be  commenced,, 
although,  as  memory,  volition,  and  intelligence  have  been 
destroyed,  he  will  preserve  no  recollection  of  any  such  pro- 
cedure. Tonic  spasm,  associated  with  temporary  embarrassment 
of  respiration,  often  arises  about  this  period;  but  as  reflex 
action  passes  away  the  respiration  becomes  tranquil  and  regular. 
The  stage  of  surgical  anaesthesia  is  now  commencing,  and  if 
the  administration  be  cautiously  continued  the  following  signs 
manifest   themselves :    The   pulse    is    fuller   than   when    the 


74  OPERATIVE    SUBGEBY. 

administration  commenced  (chloroform  acting,  for  a  while,  as 
a  cardiac  stimulant) ;  the  respiration  is  regular,  and  usually 
somewhat  stertorous ;  the  pupils  are  moderately  contracted  ; 
the  muscular  system  is  relaxed,  and  the  cornea  insensible 
to  touch.  Much  that  has  been  said  concerning  etherisation 
applies  to  the  administration  of  chloroform.  One  very  im- 
portant dilierence,  hoAvever,  deserves  emphasis  :  with  ether  it 
is  possible,  almost  with  impunity,  to  pass  beyond  the  realm  of 
retiex  action,  and  to  keep  up  an  unnecessarily  deep  narcosis  ; 
but  with  chloroform  this  is  not  the  case,  an  overdose  being 
likely,  with  but  little  warning,  to  set  up  the  most  alarming 
symptoms. 

3.    NITROUS   OXIDE. 

Properties. — Nitrous  oxide  is,  at  ordinary  temperatures 
and  pressures,  a  colourless  gas  of  somewhat  sweetish  odour 
and  taste.  It  is  supplied  by  the  instrument-makers  in  a  liquid 
state  in  iron  or  steel  cylinders,  in  which  it  exists,  at  60^  Fahr., 
at  a  pressure  of  about  1,000  lbs.  to  the  square  inch  (Barth  &  Co.). 
Cylinders  containing  liquefied  nitrous  oxide  have  labels  upon 
them  stating  the  weights  of  the  full  and  empty  C3'linders ; 
fifty  gallons  of  nitrous  oxide  gas  thus  Hquefied  weigh  fifteen 
ounces. 

Effects  of  Inhalation. — When  nitrous  oxide  is  administered 
by  means  of  a  face-piece  possessing  valves,  so  that  the  expired 
gas  is  not  re-breathed — when  care  is  taken  to  prevent  the  ad- 
mixture of  atmospheric  air — when  the  gas  is  supplied  to 
the  patient  equably,  and  as  near  as  possible  at  atmospheric 
pressure — and  when  the  j)atient  breathes,  as  he  should  be 
instructed  to  breathe,  deeply  and  freely,  the  following  effects 
are  usually  produced :  a  pleasant  sensation  is  experienced 
throughout  the  body — a  "  thrilling,"  as  Sir  Humphrey  Davy 
expressed  it — and  a  desire  to  breathe  more  deeply  arises.  If 
full  draughts  of  the  nitrous  oxide  be  inhaled,  the  sense  of 
suffocation  sometimes  complained  of  Avill  not  be  experienced. 
An  analgesic  state  is  reached  before  consciousness  is  actually 
lost.  Very  soon,  however,  anaesthesia  ensues,  and  rapidly 
deepehs.  The  florid  colour  of  the  patient's  lips  and  cheeks 
becomes  replaced  by  lividity,  or  cyanosis,  j^roportionate  to  the 
previous  colour  and  to  the  degree  to  which  the  anaesthetic  is 


NITROUS    OXIDE    AND    ETHEli.  75 

pushed.  Respiration  is  deepened  and  usually  quickened  by 
nitrous  oxide,  and  after  a  variable  though  short  period  (thirty 
t(j  sixty  seconds)  it  becomes  stertorous  and  irregular  in  rhythm. 
The  rate  of  the  pulse  is  increasingly  accelerated  throughout, 
and  if  the  administration  be  pushed  to  its  full  extent  the 
volume  of  the  pulse  diminishes.  The  pupils  usually  dilate. 
Muscular  movements,  both  clonic  and  tonic,  are  very  common, 
more  especially  in  children,  but  they  do  not  always  occur  even 
when  the  administration  is  pushed  to  its  fullest  extent.  When 
stertor  and  clonic  movement  occur,  the  administration  must 
be  discontinued,  otherwise  respiration  will  not  proceed.  Mic- 
turition is  hable  to  occur  in  children  under  the  influence  of 
the  gas.  In  dental  operations  the  available  period  of  anies- 
thesia  after  the  removal  of  the  face-piece  bears  a  sort  of  pro- 
portion to  the  length  of  time  taken  to  produce  full  anaesthesia. 
Under  ordinary  circumstances  this  period  is  of  about  thirty 
seconds'  duration. 

4.    MIXTURES     OF     ANESTHETICS. 

(i.)  Nitrous  Oxide  and  Ether. 

This  is  the  most  valuable  combination  of  anaesthetics  with 
which  we  are  acquainted.  It  is  valuable  because  the  anaes- 
thesia of  nitrous  oxide  may  be  prolonged  by  adding  ether 
vapour  when  the  patient  has  become  unconscious  from  the 
gas ;  and  also  because,  by  giving  nitrous  oxide  before  ether, 
the  former  agent  prevents  all  the  unpleasant  initial  effects 
which  would  be  produced  by  the  latter.  Nitrous  oxide  may 
either  be  followed  by  a  small  quantity  of  ether,  for  brief 
operations ;  or  by  a  considerable  quantity  for  more  prolonged 
cases.  The  effects  produced  by  the  combination  wiU  chiefly 
depend  upon — {a)  the  degree  to  which  nitrous  oxide  anaesthesia 
is  carried  before  ether  is  admitted ;  (6)  the  quantity  of  air 
allowed  during  the  transition  from  nitrous  oxide  to  ether; 
{c)  the  strength  of  the  ether  vapour  added  to  the  nitrous 
oxide ;  and  {d)  the  rapidity  with  which  the  ether  vapour  is 
admitted  whilst  nitrous  oxide  is  being  breathed.  Nitrous 
oxide  is  irrespirable  beyond  a  certain  limit,  and  hence  air 
must  be  admitted  during  the  transition  to  deep  etherisation 
(page  89),  otherwise  respiration  will  not  proceed  satisfactorily. 


76  OPERATIVE    SURGE  BY. 

(ii)  The  A.  C.  E.  Mixture. 
This  consists  of  the  following  ingredients : — 


Sp.  Gr. 

Paxts. 

Pure  Ethylic  Alcohol 

•795 

1 

„     Chloroform     ... 

1497 

2 

„    Ethylic  Ether 

•720 

3 

It  is  very  important  that  the  bottle  containing  the  mixture 
should  have  an  accurately  fitting  stopper.  It  is  best  to  make 
the  mixture  in  smaU  quantities  (about  six  ounces)  at  a  time. 
The  vapour  of  the  A.  C.  E.  mixture  is  the  most  agreeable  of 
all  the  anaesthetic  vapours.  It  has  a  fruity  odour,  and,  if 
largely  diluted  with  air,  is  very  pleasant  to  inhale.  It  has  been 
urged  that  as  the  constituents  of  the  mixture  evaporate  at 
ditferent  rates,  such  constituents  will  be  breathed  in  a  different 
proportion  to  that  intended.  This  objection  holds  good  if  a 
considerable  quantity  of  the  mixture  be  placed  in  an  inhaler 
and  the  vapour  administered.  But  if  very  small  quantities  be 
added  to  the  mask  or  cone  from  time  to  time,  such  an  objection 
almost  ceases  to  exist.  The  A.  C.  E.  mixture  should  be 
regarded  as  diluted  chloroform,  and  administered  as  though  it 
were  that  anaesthetic.  It  is  a  most  valuable  and  agreeable 
agent,  and  is  very  suitable  under  certain  conditions.  When 
nitrous  oxide  is  not  procurable,  or  when  it  is  probable  from 
the  appearance  of  the  patient  that  difiiculties  may  arise 
in  empL'ying  this  gas  before  ether,  the  A.  C.  E.  mixture 
may  with  much  advantage  be  used  as  a  preliminary  to 
etherisation. 

The  earlier  effects  produced  by  the  inhalation  of  this 
mixture  will  depend  upon  the  quantity  placed  in  the  inhaler 
and  the  degree  to  which  atmospheric  air  is  admitted.  If  ad- 
mmistered  as  directed  on  page  90,  anaesthesia  usually  becomes 
established  in  from  four  to  ten  minutes.  As  compared  with 
chloroform  narcosis,  that  of  the  A.  C.  E.  mixture  has  distinct 
advantages.  Conspicuous  among  these  is  the  stimulating 
effect  upon  the  heart.  Respiration  is  a  trifle  deeper  and 
quicker  than  under  chloroform,  a  somcAvhat  important  fact 
seeing  that  any  change  in  breathing  is  more  quickly  detected. 
Vomiting  is  far  less  common  after  this  antesthetic  than  after 
ether,  and  about  as  frequent  as  after  chloroform. 


MIXTURES    OF   ANESTHETICS.  77 

(iii.)  Chloroform  and  Alcohol. 

Chloroform  may  with  advantage  be  diluted  with  pm-e 
•ethylic  alcohol  (one-eighth  to  one-fifth),  and  the  mixture  thus 
made  administered  as  if  it  consisted  of  undiluted  chloroform. 
The  so-called  "  bichloride  of  methylene "  is  in  all  probability 
a  mechanical  mixture  of  chloroform  with  one-fifth  of  methyhc 
alcohol.  These .  mixtures  are,  cceteris  paribus,  safer  than 
chloroform  itself 

(iv.)  Morphine  and  Chloroform. 

After  even  a  small  dose  of  morphine  {e.  g.,  one-sixth  grain 
subcutaneously),  chloroform  readily  and  rapidly  produces 
anaesthesia,  but  the  greatest  caution  is  requisite  in  maintain- 
ing the  narcosis.  Very  little  chloroform  is  required  under 
such  circumstances.  The  respiration  must  be  watched  with 
the  utmost  vigilance,  for  it  is  liable  to  become  enfeebled  from 
the  combined  effects  of  the  drugs.  It  is  usually  possible, 
after  once  anaesthesia  has  been  produced,  to  maintain  an 
analgesic  effect  by  giving  but  a  few  whiffs  of  chloroform  vapour 
occasionally.  Great  caution  is  required,  and  there  are  many 
who  regard  the  combined  administration  as  dangerous.  Similar 
caution  is  requisite  in  giving  morphine  to  a  patient  deeply 
under  the  influence  of  chloroform  or  ether ;  signs  of  returning 
consciousness  should  be  allowed  to  manifest  themselves  before 
the  morphine  is  given. 


78 


CHAPTER    II. 

Modifications    in    the    Effect    of    the    Anesthetic 
dependent  upon  physical  condition,  etc. 

1.  Age. — In  infants  and  very  young  children  ether  produces 
much  irritation  to  the  dehcate  respiratory  passages,  and  the 
A.  C.  E.  mixture  should  be  preferred.  Chloroform  and  the 
A.  C.  E.  mixture  are  well  borne  in  aged  subjects,  and,  generally 
speaking,  these  anaesthetics  should  be  employed  in  such 
cases.  Ether  is  usually  considered  to  be  contra-indicated  in 
old  age,  but  if  it  be  properly  administered,  and  more  especially 
if  it  be  preceded  by  the  A.  C.  E.  mixture,  to  prevent  its  initial 
effects,  it  is  surprising  how  well  it  is  often  tolerated,  even  by 
patients  of  eighty  or  ninety  years  of  age. 

2.  Temperament. — Hysterical  patients  sometimes  give 
some  trouble,  more  especially  with  chloroform,  or  with  ether 
when  administered  with  a  copious  supply  of  air :  hence  nitrous 
oxide,  followed  by  ether,  is  the  best  ana3sthetic  in  such  cases. 
Patients  of  a  placid,  equable  temperament  take  anaesthetics 
well;  excitable  people,  and  those  whose  nervous  systems 
seem  overstrung,  are  more  liable  to  cause  delay  in  the  pro- 
duction of  anaesthetic  sleep. 

3.  Obesity — Plethora. — Generally  speaking,  patients  of 
this  group  do  not  take  ether  well,  and  the  greater  the 
exclusion  of  air  during  etherisation,  the  greater  the  difficulty 
in  the  administration.  Very  stout,  flabby  patients,  who 
are  not  full-blooded,  are  better  subjects  than  the  plethoric. 
In  the  latter  the  tongue  and  mucous  membranes  of  the 
upper  air-passages  become  much  engorged,  and  render 
respiration  difficult.  This  vascular  engorgement,  and  con- 
sequent swelling,  deserve  more  attention  than  they  have 
received.  The  difficulty  in  breathing  Avhich  they  produce 
is  not  encountered  in  sparely  built  and  antemic  subjects^ 
and   would   hence   appear   to    be    apparently    connected   in. 


EFFECT    OF   ANESTHETICS.  79 

some  way  with  the  quantity  of  blood  present  in  the  body. 
It  would  seem  that  etherisation,  more  especially  when  con- 
ducted with  a  limited  supply  of  air  (Clover's  method),  produces 
engorgement  of  the  right  side  of  the  heart  and  venous 
system  generally :  that  this  venous  engorgement  is  most 
marked  in  persons  of  an  apoplectic  type ;  and  that  in  such 
patients  the  upper  air-passages  (mouth,  nose,  etc.)  are  liable  to 
become  diminished  in  size,  or  occluded,  by  such  swelling.  In 
the  transition  from  nitrous  oxide  to  ether  the  difficulty  here 
referred  to  is  likely  to  occur,  and  hence  it  is  a  good  plan  not 
to  use  this  combination  in  such  sul»jects,  or,  if  it  be  used,  care 
should  be  taken  to  prevent  any  difficulties  in  breathing  by 
the  preliminary  insertion  of  a  small  mouth-prop  between  the 
teeth.  Plethoric  patients  may  usually  be  satisfactorily  anaes- 
thetised by  the  A.  C.  E.  mixture,  followed  by  ether  gradually 
administered  from  an  Ormsby's  inhaler. 

4.  Asthenia — Collapse— Anaemia. — Patients  of  this  class 
require  but  small  quantities  of  any  anaesthetic.  The  charac- 
teristic stertor  of  nitrous  oxide  anaesthesia  may  be  replaced 
by  shallow  rcs2:)iration,  and  care  must  be  taken  not  to  push 
the  administration  unduly.  The  same  is  more  or  less  true 
of  other  anaesthetics.  Deprivation  of  air  is  very  badly  borne 
by  these  patients,  and  hence  ether  must  be  administered  with 
plenty  of  air.  When  much  blood  has  been  lost  upon  the 
operating  table,  or  in  lengthy  operations  upon  extremely 
feeble  subjects,  it  is  better  to  allow  the  patient  to  occasionally 
exhibit  symptoms  of  imperfect  anaesthesia  than  to  unneces- 
sarily push  the  anaesthetic. 

5.  Habitual  and  excessive  use  of  Alcohol,  Tobacco, 
Morphine,  Chloral,  etc. — Patients  addicted  to  these  excesses 
frequently  give  some  trouble.  A  transitory  and  imperfect 
anaesthesia  from  nitrous  oxide  is  liable  to  arise,  and  with  ether 
or  chloroform  the  stage  of  excitement  is  often  prolonged.  x\s 
the  excessive  use  of  alcohol  and  tobacco  is  frequently  asso- 
ciated with  a  plethoric  habit,  the  phenomena  referred  to  in 
Section  .3  may  be  superadded. 

6.  Diseases  of  the  Heart  and  Blood-vessels. — Patients 
with  morbus  cordis  take  anaesthetics  well  as  a  general 
rule.  But  if  the  heart  have  undergone  extensive  degener- 
ative chang'es  much  care  wiU  be  needed.     Nitrous  oxide  and 


«0  OPERATIVE    SURGERY. 

also  ether  are  badly  borne  if  the  cardiac  affection  is  asso- 
ciated Antli  cyanosis  and  extensive  pulmonary  changes  (oedema, 
hydrothorax,  etc.).  The  A.  C.  E.  is  an  excellent  anaesthetic  for 
most  cases  of  advanced  cardiac  disease,  and.  undiluted  chloro- 
form should  be  avoided  if  possible.  Patients  who  are  the  sub- 
jects of  extensive  atheroma  should  not  be  an^sthetised  with 
ether,  as  there  is  risk  of  cerebral  haemorrhage.  The  A.  C.  E. 
mixture  or  chloroform  diluted  with  alcohol  will  be  found  to 
answer  well. 

7.  Affections  of  the  Air-passages  or  Pleurae  attended  by 
Dyspnoea  or  Cyanosis. — Generally  speaking,  ether  is  best 
avoided  in  such  cases  as  these;  and  the  A.  C.  E.  mixture 
should  be  employed.  If,  however,  the  last-named  anaesthetic 
should  cause  any  additional  distress  in  breathing,  chloroform 
(preferably  diluted  with  alcohol)  must  be  given. 

8.  Cerebral  Affections  attended  by  Impairment  of 
Consciousness. — Much  care  is  needed  in  anassthetising  patients 
who  are  aheady  more  or  less  unconscious.  When  coma  is 
present  to  a  greater  or  less  degree,  no  ana3sthetic,  or  only  the 
■smallest  quantity,  will  be  required.  The  risk  of  giving  morphine 
before  the  administration  of  the  anaesthetic  is  greater  in  these 
patients  than  in  those  whose  cerebral  functions  have  not  been 
impaired  by  disease. 


81 


CHAPTER    III. 

Preparation  of  the  Patient  for  the  Administration  of 
THE  Anaesthetic. 

The  best  time  for  the  administration  of  nitrous  oxide  is 
about  three  hours  after  soUd  food  has  been  taken.  With  ether, 
chloroform,  and  other  anoesthetics,  five  to  six  hours  should 
have  elapsed  after  solid  food,  but  a  little  clear  soup,  with  or 
without  a  glass  of  wine,  may,  in  the  case  of  feeble  patients,  be 
allowed  about  three  hours  before  the  actual  administration. 
Eggs  and  milk  should  be  withheld.  A  small  quantity  of 
brandy,  with  a  little  less  than  the  same  quantity  of  water,  may 
be  given  to  patients  whose  circulation  is  feeble,  innnediately 
before  the  administration — a  plan  more  especially  to  be  recom- 
mended Avhen  chloroform  is  to  be  employed.  Artificial  teeth 
shoidd  always  be  removed.  The  position  of  the  patient  should 
be  as  comfortable  as  circumstances  will  allow.  Whenever  it 
is  possible,  the  anaesthetist  should  ask  his  patient  to  lie  in 
that  position  which  he  assumes  on  retiring  to  rest  at  night. 
If  convenient  to  the  operator,  the  head  should  be  kept  on  the 
side — a  point  of  great  importance  if  vomiting  be  likely  to 
arise,  as  in  operations  of  emergency,  intestinal  obstruction,  &c. 
The  clothing  should  always  be  loose,  even  during  the  adminis- 
tration of  nitrous  oxide  for  a  momentary  and  simple  operation. 
Stays  and  waistbands  should  be  loosened  or  removed,  in  order 
that  respiration  may  be  freely  performed. 


^ 


CHAPTER    IV. 

The  Selection  of  the  Anaesthetic. 

The  selection  of  the  ansesthetic  should  be  regulated  by : — 
1.  The  condition  of  the  patient ;  2.  The  nature  and  length  of 
the  operation  about  to  be  performed. 

In  every  case  the  chloroformist  should  carefully  observe 
the  kind  of  patient  entrusted  to  his  care  ;  he  should  notice 
how  respiration  is  performed — more  especially  whether  nasal 
respiration  is  present  or  not ;  and  he  should  invariably  feel 
the  pulse  before  commencing  his  duties.  With  nitrous  oxide 
a  stethoscopic  examination  of  the  chest  is  unnecessary,  unless 
it  is  obvious  from  an  inspection  of  the  patient,  or  from  other 
indications,  that  some  intra-thoracic  affection  exists.  With 
other  anaesthetics  it  is  usually  a  good  plan  to  Usten  to  the 
chest ;  but  no  prolonged  stethoscopic  examination  need  be 
resorted  to  unless  special  indications  exist. 

Generally  speaking,  nitrous  oxide  is  the  best  anaesthetic 
for  very  brief  operations  ;  and  ether  for  longer  cases.  As 
akeady  mentioned,  the  disadvantages  connected  with  the 
latter  ansesthetic  may  to  a  great  extent  be  removed  by  pre- 
ceding the  inhalation  by  nitrous  oxide  or  the  A.  C.  E.  mixture. 
There  are  of  course  many  cases  in  which  neither  nitrous  oxide 
nor  ether  should  be  given  ;  and  the  following  table  has  been 
drawn  up  to  show  these  exceptions. 


Cases  suitable  for  the  A.  C.  E. 
mixture. 


Infants  and  very  young  children. 

Most  patients  above  60  or  65  years  of 
age.  (2) 

Extreme  obesity,  especially  if  asso- 
ciated with  plethora.  ('■') 

Most  cases  of  advanced  cardiac  disease. 

Affections  of  the  air  pnssages  or  i)leura6, 
nttendcd  by  dyspnci-a  or  cyanosis. 


Cases  suitable  for  Chloroform.  (') 


Prolonged  nasal  or  C)ral  operations  (8), 
and  those  with  the  actual  cautery. 

Cases  in  which  neither  ether  nor  the 
A.  C.  E.  mi.xture  is  well  borne. 

Labour. 

Marked  atheroma. 


THE    SELECTION    OF    THE    ANAESTHETIC.  S3 

Note  on  Abdominal  Section  :  operations  upon  or  near  large  vessels,  dtc. 

There  ai-e  cases  in  which  the  venous  engorgement  of  ether  might  constitute 
a  serious  difficulty  or  danger,  e.i/.,  in  the  removal  of  ghmds  at  the  root  of  neck, 
tracheotomy,  the  ligature  of  large  arteries,  &c.  In  these  cases  the  A.  C.  E. 
mixture  or  chloroform  is,  from  the  point  of  view  of  the  operator,  preferable  to 
ether.  Again,  in  abdominal  section,  chloroform  undoubtedly  possesses,  so  far  as 
the  performance  of  the  operation  goes,  advantages  over  ether ;  for  the  respiration 
is  more  tranquil,  the  engorgement  of  the  parts  is  less,  and  there  is  less  lial)ility 
to  cough.  WTiether  the  advantages  referred  to  should  be  allowed  to  outweigh 
the  one  great  advantage  of  ether — its  greater  safety — is  a  matter  of  opinion. 


(').  Chloroform  may  with  advantage  be  diluted  with  a  small  quantity  of 
alcohol  (page  77). 

(2).  It  is  often  a  good  plan  in  these  cases  to  commence  with  the  A.  C.  E. 
mixture  and  to  continue  with  ether  fi-om  an  Ormsby's  inhaler,  taking  care  not 
to  deprive  the  patient  of  air  to  too  great  an  extent. 

P).  It  is  an  excellent  practice  to  place  the  patient  deeply  imder  ether,  and 
flubsequently  to  maintain  the  anaesthesia  by  chlorofonn  administered  through 
the  nose  or  mouth  by  means  of  Junker's  apparatus. 


o2 


84 


CHAPTER   y. 
The  Administration  of  the  Anesthetic. 

1.    ETHER. 

Clover's  Inhaler. — One  of  the  most  convenient  appliances 
for  the  administration  of  ether  is  Clover's  portable  regulating 
inhaler  (Fig.  16). 

It  consists  of  a  face-piece,  an  ether  chamber,  and  a  bag. 
When  the  face-piece  fits  the  face  accurately,  all  communica- 
tion Avith  the  outside  air  is  shut  off",  and  the  patient  breathes 

backwards  and  forwards  into 
the  bag.  That  part  of  the 
apparatus  between  the  face- 
piece  and  bag  consists  essen- 
tially of  a  hollow  sphere  for 
holding  the  ether,  the  latter 
being  poured  into  the  sphere 
through  the  little  projecting 
tube  on  the  side.  One  half 
of  the  sphere  is  surrounded 
by  a  hermetically  scaled 
water-jacket,  thus  giving  the  apparatus  its  Avell-known  shape. 
By  heating  this  part  of  the  inhaler,  the  water  in  the  water- 
jacket  takes  up  and  retains  heat,  thus  causing  a  sufficiently 
brisk  evaporation  of  the  ether  in  the  adjacent  sphere.  With- 
out entering  into  a  detailed  description  of  this  ingenious  appa- 
ratus, it  may  be  said  that,  when  the  ether-chamber  is  made  to 
revolve,  the  inspirations  and  expirations  of  the  patient  are 
thrown  to  the  desired  extent  over  the  ether  contained  in  the 
sphere.  Thus,  when  the  ether-chamber  is  revolved  so  that  the 
indicator  points  to  "  1,"  one-quarter  of  the  current  ])asses 
over  the  ether  and  the  other  three-quarters  pass  to  and  from 
the  bag  Avithout  being  thus  diverted.  When  the  indicator  is 
at  "  2,"  two-quarters,  or  one-half,  of  the  current  passes  over 


Fig.  16.— clover's  inhaler. 


ADMINISTRATION    OF   ETHER.  85 

the  ether.  When  the  indicator  is  at  "  3,"  three-quarters  of 
the  current  arc  diverted.  When  the  indicator  is  at  "  F  "  (full), 
four-quarters,  or  the  whole,  of  the  current  is  made  to  pass 
over  the  ether  as  it  travels  betAveen  the  face-piece  and  the 
bag. 

Method  of  using  the  Inhaler. — (1)  In  cold  weather,  and 
when  about  to  anaesthetise  powerfully-built  subjects,  place  the 
etlier-chamber  in  As-arni  water  for  three  or  four  minutes.  (2) 
Throw  out  any  water  that  ma}^  have  entered,  and  pour  into 
the  sphere,  by  the  tube  provided  for  the  purpose,  about  an 
ounce  and  a-half  of  ether.  (3)  Turn  the  indicator  to  "  0." 
(4)  Accurately  but  gently  adapt  the  face -piece,  during  an 
expiration,  to  the  face  of  the  patient ;  by  pressing  it  a 
little  more  tightly  during  expiration  than  during  inspiration 
the  bag  will  become  distended  with  expired  air.  (5)  Allow 
the  patient  to  breathe  to  and  fro  for  about  half  a  minute. 
(6)  Very  gradually  rotate  the  ether-chamber,  so  that  the 
"0"  on  the  apparatus  moves  gradually,  about  one-eighth 
of  an  inch  at  a  time,  away  from  the  indicator.  (7)  Should 
swallowing  or  coughing  arise,  turn  back  somewhat  till  these 
signs  of  irritation  have  subsided.  (8)  Should  excitement 
or  strugghng  occur,  do  not  discontinue  the  administration. 
(9)  When  the  cheeks  and  ears  tend  to  become  dusky  in 
colour,  admit  a  breath  of  fresh  air  by  removing  the  inhaler, 
and  gradually  increase  the  strength  of  the  vapour,  remem- 
bering that  the  more  air  admitted  the  more  ether  must 
be  given  in  order  to  secure  deep  ana?sthesia.  (10)  As  a 
general  rule,  the  inhaler  should  be  removed  every  fourth 
or  fifth  respiration  for  a  breath  of  fresh  air ;  this  rule  will, 
however,  require  modification  in  the  earlier  and  later  stages 
of  the  administration ;  in  the  earher  stages  it  will  usually  be 
found  advantageous  to  give  somewhat  less  air  than  that 
indicated,  in  the  later  stages  the  inhaler  need  only  be 
apphed  occasionally.  (11)  When  once  surgical  anaesthesia 
has  become  established  the  indicator  may  be  kept  at  "  1  " 
or  "  2,"  except  in  the  case  of  ver}-  strongly  built  or  alcoholic 
subjects  who  require  considerable  quantities  of  the  anaesthetic. 
(12)  Watch  respiration  carefully  and  the  pulse  occasionally ; 
should  the  breathing  become  feeble  or  shallow,  or  the  pulse 
weak,  as  it  might  become  in  extremely  feeble  patients,  the 


hb 


OPERATIVE    SUBGEBY. 


ana?sthetic  should  be  discontinued  till  these  symptoms  have 
passed  off! 

Ormsby's  Inhaler,  which  consists  of  a  face-piece  and  bag, 
between  which  there  is  a  sponge  for  the  reception  of  the 
ether,  although  simpler  in  construction,  possesses  some  dis- 
advantages as  compared  to  Clover's  apparatus.  About  one 
ounce  of  ether  should  be  poured  upon  the  sponge,  and  the 
inhaler  should  be  very  gradually  apphed  to  the  face,  other- 
A\ise  much  coughing  and  irritation  will  result.  More  ether 
is  used  than  with  Clover's  inhaler,  and  the  depth  of  etherisa- 
tion cannot  be  quite  so  satisfactorily  regulated  as  with  the 
latter  apparatus.  Ormsby's  inhaler  may,  however,  be  em- 
ployed with  advantage  fo:  rapidly  inducing  etherisation  after 
nitrous  oxide,  the  face-piece  employed  for  the  latter  agent 
being  quickly  replaced  by  the  ether  inhaler ;  and  it  is  equally 
useful  when,  after  having  administered  a  small  quantity 
of  the  A.  C.  E.  mixture  on  an  open  inhaler,  it  is  wished  to 
keep  up  the  anaesthesia  by  means  of  ether. 

The  simple  felt  cone,  with  a  sponge  at  its  apex,  is  to  be 
recommended  for  use  in  those  cases  which  require  very  little 
ether  and  a  very  copious  supply  of  air. 

2.  CHLOROFORM. 

One  of  the  best  inhalers  for  the  administration  of  chloro- 
form is  Junker's  (Fig.  17).     It  consists  of  a  graduated  bottle  for 

the  antosthetic,  hand- 
bellows  and  tubes  for 
pumping  air  through 
the  chloroform,  and  a 
face-piece  for  the  recep- 
tion and  transmission 
to  the  patient  of  a 
chloroform  vapour  well 
diluted  with  air.  Tlie 
bottle  for  the  anu'Sthe- 
tic  is  suspended  by  a 
hook  from  the  coat 
of  the  administrator. 
About  six  drachms  of 
bichloride    of 


Fig.    17. — JXTNKKIt'S    IXIIAXER. 


chlorofonn     (chloroform    and     alcohol,     or 


ADMINISTRATION    OF    GHLOROFOBM. 


87 


methylene ")  are  placed  in  the  bottle ;  the  face-piece  is 
brought  near  the  face ;  gentle  pressure  is  made  upon  the 
hand-bellows ;  and  thus  air  containing  chloroform  vapour 
is  administered  to  the  patient.  It  is  said  that,  at  a  tempera- 
ture of  55^^  Fahr.,  and  with  one  ounce  of  chloroform  in  the 
bottle,  not  more  than  one  and  one-hfth  minim  of  chloroform 
is  vapourised  by  a  single  compression  of  the  bellows.  With 
undiluted  chloroform  anesthesia  becomes  established  in  from 
four  to  ten  minutes.  When  once  the  stage  of  surgical  antes- 
thesia  has  been  reached  vigilance  must  be  exercised,  for 
unlike  ether,  chloroform  tends  to  set  up  symptoms  of  respira- 
tory and  cardiac  depression  if  the  anaesthetic  be  incautiously 
administered.  The  chief  objection  to  Junker's  apparatus  is 
that  it  is  somewhat  difficult  to  watch  the  pulse  whilst  em- 
ployed in  pumping  the  bellows  and  holding  the  face-piece ; 
but  if  the  head  of  the  patient  be  kept  upon  the  side,  the 
face-piece  may  be  retained  in  position  by  means  of  a  loose 
towel  beneath  it,  and  thus  one  hand  of  the  administrator  will 
be  fit'ec.  By  the  employment  of  a  flexible  metal  tube  instead 
of  a  face-piece,  anaesthesia  may  be  efliciently  maintained  during 
operations  about  the  mouth  or  nose,  e.g.,  in  staphyloraphy, 
removal  of  tongue,  &c.,  or  the  indiarubber  tube  of  Junker's 
apparatus  may  be  attached  to  a  special  form  of  gag,  possessing 
small  metal  tubes  to  convey  the  chloroform  vapour  to  the 
back  of  the  mouth  during  such  operations  (Hewitt's  gag). 

Chloroform  is  very  commonly  administered  by  dropping 
or  pouring  small  quan- 
tities at  a  time  on  a 
folded  towel  or  piece  of 
lint.  When  administer- 
ing the  agent  without 
any  special  apparatus,  a 
drop-bottle  should  be 
used.  The  accompany- 
ing figure  represents  a 
simple  mask  (kno^vn  as 
Skinner's)   and  a   drop- 


Fig.  18. 


-bBJ^'^EE'b   MAfei.  A>D   CULOh-UFOKil 
DROr-BO.XLK. 


bottle  for  the  chloroform 

(Fig.  18).     For  the  safe  employment  of  this  method  all  hurry 

must  be  avoided  ;  three  or  four  drops  of  chloroform  should 


88  OPERATIVE    SURGERY. 

at  tirst  be  given ;  in  a  few  seconds  five  to  ten  more  ;  when 
the  odour  of  the  chloroform  has  nearly  passed  off  five  to  ten 
dro^js  more  may  be  added,  and  so  on.  Children  require 
smaller  quantities  than  these.  Care  must  be  taken  not  to 
employ  a  saturated  piece  of  lint  or  flannel ;  and  a  copious 
supply  of  air  is  imperatively  necessary  throughout. 

In  whatever  manner  chloroform  is  administered,  the  anes- 
thetist must  be  careful  not  to  push  the  anaesthetic  when  deej) 
respirations  accompany  or  folloAv  the  stage  of  excitement,  for 
it  is  then  that  an  overdose  is  most  likely  to  be  given ;  and 
it  is  a  good  plan,  when  signs  of  surgical  anesthesia  commence 
to  appear,  to  discontinue  the  administration  for  a  moment 
or  two,  and  allow  a  few  respirations  of  air  to  be  taken  before 
proceeding  with  the  inhalation.  The  pulse  must  be  watched 
throughout,  as  it  frequently  gives  the  first  indication  of  danger. 
The  respiration  should  be  listened  to,  and  the  colour  of  the 
hps  and  ears  observed.  Stertor  should  not  be  allowed  to 
become  too  deep.  The  pupils,  which  are  moderately  con- 
tracted when  surgical  anaesthesia  is  satisfactorily  established, 
should  be  looked  at  from  time  to  time. 

3.   NITROUS   OXIDE. 

In  administering  nitrous  oxide  it  is  advisable  to  employ 
two  cylinders  of  the  Hquefied  agent,  so  that  should  one  fall 


Fig.    19. — CYtlNDEBS  FOR  NITE0T7S  OXTDB, 

short,  or  fail  to  work  during  the  administration,  the  other 
may  at  once  be  turned  on  (Fig.  19).  By  rotating  the  foot- 
key,  nitrous  oxide  gas  is  Hberated  and  made  to  pass  through  a 
small  indiarubber  tube  to  a  bag,  from  which  it  may  be  inhaled 
by  means  of  a  face-piece  and  stopcock.  The  accompanying 
drawing  (Fig.  20)  shows  the  most  convenient  arrangement 
for  the  purpose,  the  inspiratory  and  expiratory  valves,  which 


ADMINISTRATION    OF    GAS. 


89 


are  necessary  in  order  to  prevent  re-breathing  of  the  gas,  being 
placed  in  the  stopcock.  As  arranged  in  the  figure,  air  Avould 
be  breathed  through  the  apparatus  as  indicated  by  the  arrows; 
but  if  the  handle  h  be  moved  round,  nitrous  oxide  will  be  in- 
haled fi-oni  the  bag  and  escape 
from  the  expiratory  valve  shown 
above.  In  administering  the 
gas  the  following  brief  direc- 
tions should  be  attended  to  : — 
(1)  If  the  operation  is  to  be 
within  the  mouth,  a  small 
"  prop  "  should  be  inserted  be- 
tween the  teeth;  (2)  The  bag 
should  be  half-filled  with  gas ; 
(3)  The  face-piece  should  be 
very  accurately  appUed  to  the 
face;  (4)  Air  should  first  be 
breathed  through  the  apparatus;  (5)  The  patient  should  be 
instructed  to  breathe  freely  and  deeply,  and,  whilst  he  is  thus 
breathing  air  through  the  apparatus,  nitrous  oxide  should  be 
turned  on ;  (6)  The  bag  should  be  kept  nearly  full  throughout 
the  administration ;  (7)  AYhen  signs  of  nitrous  oxide  nar- 
cosis occur  the  face-piece  should  be  removed  or  air  otherwise 
admitted. 


Fig.    20. — NITROTTS   OXIDK   APPARATUS. 


4.    MIXTURES   OF   ANAESTHETICS. 

Nitrous  Oxide  and  Ether. — There  are  several  ways  of 
administering  these  anaesthetics  together,  and  space  will  not 
permit  a  description  of  them.  Whatever  plan  is  chosen,  it 
will  be  found  advisable  to  freely  administer  nitrous  oxide 
before  ether  is  admitted,  and  to  pay  a  due  regard  to  the 
necessity  of  allowing  a  small  quantity  of  air  whilst  proceeding 
from  nitrous  oxide  amesthesia  to  that  of  ether.  If  no  air 
be  allowed,  respiration  cannot  continue ;  if  too  much  be  given, 
the  patient  will  recover  from  the  effects  of  the  gas,  and  so 
the  very  purpose  for  which  the  latter  Avas  administered 
will  be  defeated.  Clover's  gas-and-ether  apparatus  is  em- 
ployed by  some ;  others  prefer  to  pass  nitrous  oxide  through 
Clover's  portable  regulating  inhaler,  and  to  turn  on  ether 
whilst  nitrous  oxide  is  being  inhaled ;  and,  lastly,  there  are 


90  OPERATIVE    SURGE  BY. 

advocates  for  the  plan  of  first  administering  nitrous  oxide  by 
the  ordinary  means,  and  rapidly  changing  the  gas  apparatus- 
for  a  prcvioush^  charged  Ormsby's  ether  inhaler. 

'The  A.  C.  E.  Mixture. — This  mixture  should  be  adminis- 
tered in  small  quantities  at. a  time,  with  a  copious  supply  of 
au".  A  Skinner's  mask  will  suffice  for  children,  and  for  weakly 
adults ;  but  in  the  case  of  stronger  persons  some  kind  of  felt 
or  leather  cone,  provided  with  a  small  sponge,  and  permitting 
a  free  supply  of  air,  ^vill  be  necessar}^  The  quantity  of  the 
mixture  which  should  be  added  at  one  time  should  be  regu- 
lated by  the  age  and  strength  of  the  patient.  With  children 
and  feeble  persons,  sprinkhng  from  a  drop-bottle  upon  the 
mask  or  cone  will  be  sufficient :  but  with  more  vigorous 
individuals  half-drachm  doses  will  be  required  to  secure 
satisfactory  ancesthesia.  It  is  a  bad  plan,  and  one  hkely  to  be 
followed  by  evil  consequences,  to  place  a  large  quantity  of  the 
mixture  at  one  time  within  an  inhaler,  for  the  objection  to 
anaesthetic  mixtures  would  thus  at  once  apply.  Nor  should  a 
Clover's  or  Ormsby's  inhaler  be  used,  for  air  limitation  with 
chloroform,  or  any  mixture  containing  chloroform,  is  to  be 
deprecated.  The  administration  should  be  maintained  as  if 
chloroform  were  being  employed,  though,  of  course,  a  con- 
siderably larger  quantity  of  the  A.  C.  E.  mixture  than  of 
chloroform  will  be  required  to  produce  anaesthesia.  As  with 
chloroform,  plenty  of  time  (five  to  ten  minutes)  should  be 
taken  in  estabhshmg  surgical  anaesthesia. 

Chloroform  and  Alcohol  {"Bichloride  of  Methylene"). — 
Mixtures  of  chloroform  and  alcohol  should  be  administered  in 
a  similar  manner  to  chloroform.  It  may  be  as  weU,  however,, 
to  point  out  that,  with  Junker's  inhaler,  difficulty  may  some- 
times be  experienced  in  ansesthetising  by  means  of  chloroform 
diluted  with  as  much  as  one-fifth  or  so  of  alcohol,  except  in 
the  case  of  children.  The  so-caUed  "  bichloride  of  methylene," 
which  appears  to  consist  of  chloroform  diluted  with  methylic 
alcohol,  should  be  administered  with  all  the  care  and  precau- 
tion which  are  essential  in  giving  undiluted  chloroform. 


91 


CHAPTER    VI. 

The  Chief  Difficulties  and  Dangers  connected  with 
THE  Anesthetic  State — their  Management  and 
Treatment. 

The  administrator  should  have  at  hand  the  following 
appliances  and  remedies  in  case  of  need : — Tongue  forceps, 
Mason's  gag,  nitrite  of  amyl  capsules,  brandy,  liq.  amnion,  fort., 
a  hypodermic  syringe,  and  instruments  for  tracheotomy.  In 
mouth  opeiations  he  should  also  have  several  sponges,  firmly 
fixed  m  strong  sponge-holders. 

However  skilfiil  the  administrator  may  be,  he  will  be 
certain  to  meet  with  difiiculties  fi'om  time  to  time,  and  he 
should  therefore  ever  be  on  the  alert,  even  in  cases  which 
appear  to  be  of  the  most  simple  nature.  Very  nervous 
patients  require  encouragement,  and  should  be  instructed  how  to 
inhale  the  anaesthetic.  Should  excitement  or  struggling  occur 
under  nitrous  oxide  or  ether,  the  anaesthetic  may  unhesitatingly 
be  j)ushed  ;  but  with  chloroform,  or  the  A.  C.  E.  mixture, 
much  caution  is  requisite  at  this  stage,  and  a  very  copious 
supply  of  air  must  be  allowed.  It  is  best  not  to  restrain  the 
patient's  movements,  imless  there  is  a  fear  of  his  injuring 
himself,  or  interfermg  with  the  administration.  Coughing 
and  swallowing  in  the  very  early  stages  point  to  too  strong  a 
vapour,  and  they  should  be  met  by  a  diminution  in  the 
strength  of  the  ansesthetic.  Should  they  tend  to  arise, 
however,  after  surgical  anaesthesia  has  become  estabhshed, 
they  should  be  met  by  increasing  the  strength  of  the  vapour 
as  quickly  as  the  circumstances  will  permit.  Vomiting,  which 
wUl  not  take  place  if  the  anaesthesia  be  profound,  is,  practically 
speaking,  always  preceded  by  acts  of  deglutition,  and  when 
such  acts  occur  the  depth  of  the  anaesthesia  must  at  once 
be  increased  if  it  be  desired  to  avert  vomiting.  With  ether 
there  is  no  danger  in  thus  rapidly  producing  deeper  narcosis ; 


92  OPERATIVE    SUBGEBY. 

but  this  cannot  be  said  so  confidently  of  chloroform.  Difficulty 
is  sometimes  experienced  in  producing  full  surgical  anixjsthesia, 
some  patients  requiring  very  la'ge  doses  of  the  anassthetic 
before  perfect  quietude  is  secured.  Should  this  occur  with 
nitrous  oxide,  the  admixture  of  a  small  quantity  of  air,  by  the 
side  of  the  face-piece  or  elsewhere,  may  be  suspected.  It  is 
well  known  that  many  fatalities  have  occurred  with  chloroform 
during  or  immediately  after  the  stage  of  excitement,  the 
explanation  being  that  the  patient,  having  had  but  httle  air 
for  some  moments,  by  reason  of  the  breath  having  been  held, 
inhales  with  the  followmg  deep  respirations  a  large  quantity 
of  chloroform,  and  as  the  inhalation  of  chloroform  durmg 
even  a  minor  degree  of  asf)hyxia  is  highly  dangerous,  serious 
consequences  may  follow.  Should  it  be  found  difficult  to 
secure  full  surgical  anaesthesia  with  ether,  a  sponge  wrung  out 
of  hot  water  may  be  applied  to  the  sides  of  Clover's  inhaler, 
in  order  to  get  a  sufficient  quantity  of  ether  evaporated,  and 
air  should  be  sj)aringiy  admitted  for  a  time,  unless  contra- 
indications exist.  Just  as  there  are  patients  who  require 
large  doses  of  an  anassthetic,  so  there  are  others  who  display 
an  opposite  peculiarity.  The  weaker  and  more  fragile  the 
patient,  the  more  rapidly  wiU  the  anaesthetic  produce  its 
effects.  Ansemic  and  debilitated  individuals,  more  especially 
if  advanced  in  years,  will  be  found  to  exhibit  very  different 
effects  from  those  which  have  been  described  as  taking  place 
in  healthy  and  vigorous  subjects. 

Respiration  should  be  carefuUy-  listened  to  from  the 
commencement  to  the  end  of  the  administration.  Whenever 
it  is  difficult  to  hear  the  breathing  the  administrator  should, 
by  other  means,  make  certain  that  it  is  proceeding  in  a  satis- 
factory manner,  bearing  in  mind  the  fact  that  movements  of 
the  chest  and  abdomen  wiU  continue  for  a  time  if  the  air- way 
is  completely  obstructed.  It  is  important  that  the  aniesthctist 
should  recognise  the  two  distinct  ways  in  which  resjDiration 
may  fail  during  antesthetic  sleep.  It  may  fail — (1)  in  conse- 
quence of  some  mechanical  impediment  to  the  entry  and  exit 
of  air;  or  (2)  independently  of  any  such  obstruction  in  the 
air-way,  i.e.,  from  feebleness  or  paralysis  of  the  respiratory 
mechanism. 

Obstructive  Respiratory  Failure. — When  it  is  obvious  that 


DANGERS    UNDER    ANESTHESIA.  93 

there   is   some   obstruction   to   breathing,  we  must  at   once 
endeavour  to  discover  the  cause.     An  adventitious  substance 
may  be  present — mucus,  blood,  pus,  vomited  matters ;  a  purely 
anatomical  reason  may  exist — the  tongue,  or  epiglottis,  may, 
by  reason  of  the  position  of  the  head  or  lower  jaw,  be   in 
contact  with  the  pharj^nx ;  such  a  degree  of  vascular  engorge- 
ment and  swelling  of  the  tongue  or  other  parts  in  the  uppe  • 
air-passages  may  have  arisen  as  to  prevent  the  proper  entry  of 
air ;  or,  lastly,  laryngeal  spasm  from  too  strong  a  vapour  or 
other  causes  may  have  been  produced.     To  carefully  maintain 
a  free  air- way  is  of  paramount  importance.     With  regard  to 
blood,  vomited  matters,  &c.,  entering  the  larynx,  the  adminis- 
trator should,  whenever  there  is  a  possibility  of  this  occurring, 
strive  to  keep  the  patient's  head  well  turned  to  the  side,  and 
to  remove  all  blood,   &c.,  from  the  back  of  the  throat   by 
repeated  sponging.     In  operations  in  or  about  the  mouth  or 
nose,  accompanied  by  free  haemorrhage — e.g.,  removal  of  the 
superior  maxilla — the  position  indicated  should  be  carefully 
maintained,  if  convenient  to  the  operator ;  or  the  head  should 
be   throAni   very  far   back  over   the   edge  of  the  table.     In 
the  removal  of  post-nasal  adenoids  by  means  of  the  "  arti- 
ficial nail,"  it  is  a  good  plan  to  put  the  patient  under  ether, 
gently  raise  him  to  the  sitting  position,  and  keep  the  head  and 
shoulders    well  forward  during  the  operation,  so  that  blood, 
&c.,  may  freely  drain  away  through  the  mouth  and  nose.     In 
all  mouth  and  nose  cases,  with  fi-ee  haemorrhage,  anaesthesia 
should  never  be  very  profound,  except,  perhajjs,  just  at  first ; 
coughing  and  swallowing  should  be  allowed  to  occur  occasion- 
ally, and  the  operator  should  not  object  if  the  unconscious 
patient  is  a  little  restless  at  times.     In  connection  with  the 
anatomical   conditions  which  may  obstruct  breathing,  these 
may  usually  be  easily  removed,  either  by  throwing  the  head 
weU  backwards,  thus  removing  tlixB  back  of  the  tongue  and 
the  epiglottis  from  the  pharynx  and  larynx  ;  or  pushing  the 
loAver  jaw  forward,  which  has  the  same  eftect  and  is   more 
easily  done;  or  by  placing  a  small  mouth-proj)  between  the 
teeth,   if  nasal  respiration  be  inadequate;    or  by  separating 
the  lips  of  edentulous  patients,  &c.      Should  it   be    found, 
prior  to  the  operation,  that  nasal  obstruction  is  present,  the 
anaesthetist  should  insert  a  smaU  mouth-prop  between  the 


94  OPERATIVE    6UEGEBY. 

teeth  before  commencing  the  administration ;  and  he  may 
with  advantage  adopt  a  similar  precaution  in  the  case  of 
plethoric,  short-necked  patients,  who,  as  already  explained, 
are  hable,  more  especially  under  ether,  to  suffer  from  transient 
difficulties  of  respiration.  Loud  snoring  is  often  due  to  a 
swollen  tongue,  which  vibrates  against  the  pharynx,  and  when 
it  occurs  it  is  advisable  to  keep  the  lower  jaw  pressed  well 
forward,  in  order  to  prevent  obstructed  breathing.  With  all 
anaesthetics  it  wdll  be  found  a  good  plan  to  adopt  a  similar 
course,  should  any  tendency  to  embarrassed  breathing  arise. 
Laryngeal  spasm,  which  is  known  by  high-pitched  crowing 
respiration,  often  results  from  too  strong  a  vapour,  and  is  to  be 
met  by  withdrawing  the  anaesthetic  till  the  spasm  has  passed  off 
It  may,  however,  be  the  reflex  result  of  certain  operative  pro- 
cedures during  moderately  deep  anaesthesia,  and  may  lead,  under 
chloroform,  to  circulatory  depression  in  a  short  space  of  time. 
Uterine,  pelvic,  and  rectal  operations  are  the  most  likely  to 
initiate  this  condition,  and  hence  deep  anaesthesia  is  always  ad- 
visable in  such  cases.  Should  the  above-mentioned  manoeuvres 
fail  to  relieve  the  obstruction  which  is  present,  the  mouth  should 
at  once  be  opened,  and  the  tongue  pulled  forcibly  forward,  when 
breathing  will  almost  certainly  recommence.  If,  however, 
respiration  does  not  take  place,  forcible  pressure  upon  the  chest 
should  be  made,  with  the  object  of  overcoming  any  obstruc- 
tion in  or  about  the  larynx.  If  air  cannot  thus  be  forced  out 
of  the  chest,  any  further  attempt  at  artificial  respiration  will 
probably  be  useless.  Still,  the  arms  may  be  extended  once  or 
twice  by  Silvester's  method,  and  if  no  beneficial  result  follow, 
tracheotomy  should  be  performed,  and  artificial  respiration  at 
once  commenced.  No  attention  need  be  paid  to  the  pulse 
when  respiration  obviously  fails  in  consequence  of  some 
obstruction;  otherwise  delay  in  overcoming  the  obstruction 
will  arise. 

Non-obstructive  Failure  of  Respiration. — The  other  form 
of  failure  of  respiration  is  of  a  wholly  different  nature,  for  it 
occurs  independently  of  any  obstruction,  and  is  characterised 
by  a  more  or  less  gi*adual  cessation  of  all  thoracic  and  abdo- 
minal respiratoiy  movements.  Although  such  failure  usually 
proceeds  from  feebleness  or  actual  })aralysis  of  the  nervous 
mechanism  of  respiration,  other  factors  are  sometimes  present. 


DANGERS    UNDER    ANESTHESIA.  95 

Tor  example,  the  bony  ft-amework  of  the  chest  may,  from 
senile  or  other  changes,  fail  to  respond  in  a  satisfactory  man- 
ner to  the  demands  made  upon  respiration ;  or  the  respiratory 
muscles  may  be  Aveak  and  similarly  unfitted  for  any  unlooked- 
for  exertion ;  or  lastly,  by  reason  of  pre-existing  pulmonary  or 
pleural  disease,  the  performance  of  the  necessary  respirator}'' 
movements  may  become  a  matter  of  difficidty  or  even  impos- 
sibility. Respiratory  failure  of  this  kind  is  most  common 
under  chloroform,  though  it  may  arise  under  nitrous  oxide 
or  ether.  It  usually  co-exists  with  feeble  cardiac  action  and 
low  vascular  tension,  sometimes  being  apparently  dependent 
upon  these  conditions,  as  for  example  in  the  case  of  shock 
from  loss  of  blood  and  other  causes.  Syncope  occurring  upon 
the  operating- table  and  arising  from  one  or  other  of  the 
conditions  to  be  presently  described  may,  if  the  administrator 
be  Avatching  the  breathing,  first  show  itself  by  feeble  respiration. 
With  regard  to  the  direct  effects  of  anesthetics  upon  respira- 
tion, the  late  Hyderabad  Commission  have  shown  that  chloro- 
form, when  administered  to  the  lower  animals  in  toxic  doses, 
lowers  vascular  tension  and  paralyses  respiration,  the  action 
of  the  heart  continuing  after  actual  cessation  of  breathing  has 
taken  place.  It  is  urged  by  the  Commission  that  this  se- 
quence of  events  occurs  in  the  human  subject ;  and  it  is  pro- 
bable that,  when  respiration  ceases  purely  from  the  direct 
ejfects  of  chloroform,  the  heart  may  continue  beating,  though 
feebly,  for  a  brief  space  of  time.  The  practical  conclusion 
arrived  at  by  the  Hyderabad  Commission  is  that  when  ad- 
ministering chloroform  the  whole  attention  should  be  directed 
to  respiration  and  that  the  pulse  should  be  disregarded.  As 
will  be  ]5resently  shown,  however,  the  pulse  may  often  give 
very  early  indications  of  impending  danger,  and  for  this 
reason  should  be  carefully  watched  in  administering  chloro- 
form. Shallow  or  imperceptible  breathing,  with  cyanosis,  is 
nearly  always  associated  with  an  extremely  feeble  pulse,  but  this 
combination  of  symptoms  is  much  more  pronounced  under 
chloroform  than  under  ether.  If  ether  be  administered  to  a 
poisonous  extent,  gradual  failure  of  respiration  wiU  occur ;  but, 
by  reason  of  the  stimulant  effect  of  ether  upon  the  heart,  the 
patient  may  nearly  always  be  rescued  by  artificial  respiration. 
The  first  remedy  which  should  be  appHed  in  aU.  these  cases 


96  OFJbJBATIVE    SUIIGEEY. 

is  artificial  respiration,  commenced  by  a  compression  of  the 
thorax.  In  minor  cases,  after  two  or  three  compressions, 
breathing  will  recommence,  and  may  be  further  stimulated  by 
flicking  the  chest  with  a  wet  towel,  or  by  briskly  rubbing  the 
hps  and  cheeks  of  the  patient  with  a  dry  cloth.  If,  however, 
this  should  not  be  the  case,  systematic  artificial  respiration  by 
Silvester's  method  should  be  resorted  to,  and  sedulously  main- 
tained, even  though  the  threatening  symptoms  were  originally 
cardiac.  Whilst  artificial  respiration  is  thus  proceeding,  nitrite 
of  amyl  may  be  appHed  to  the  nostrils,  and  other  remedial 
measures  appropriate  in  syncope  may  be  resorted  to  if  deemed 
advisable.  The  tongue  forceps  need  not  be  used  if  it  is  obvious 
that  a  free  air-current  to  and  from  the  chest  exists ;  but  care 
should  of  course  be  taken  to  maintain  this  free  air- way  during 
artificial  respiration.  The  latter  should  be  continued  for  at 
least  an  hour,  or  for  longer  if  any  signs  of  animation  can  be 
detected. 

Cardiac  Failure. — -The  circulation  may  become  enfeebled 
or  actually  arrested  during  the  administration  of  an  anaes- 
thetic. Generally  speaking,  the  weaker  the  patient  the  more 
likely  wiU  the  heart  be  to  show  signs  of  failure.  Putting  aside 
morloid  cardiac  and  pulmonary  conditions,  there  is  clinical 
evidence  to  show  that  failure  of  the  heart  during  anaesthesia 
may  arise  in  at  least  four  ways  :  viz.,  (1)  reflexly ;  (2)  during 
incidental  asphyxia ;  (3)  from  loss  of  blood  or  other  exhaust- 
ing influences ;  and  (4)  as  the  result  of  an  excessive  dose  of 
the  antesthetic.  Temporary  reflex  arrest  of  the  heart's  action 
may  take  place  under  all  angesthetics,  more  especially,  it  is 
said,  if  the  anaesthesia  be  not  profound.  The  severer  cases 
of  reflex  syncope  would  seem,  however,  to  be  met  with  chiefly, 
if  not  exclusively,  under  chloroform.  With  regard  to  the 
asphyxial  element  during  anaesthesia,  it  may  be  said  that  under 
chloroform  the  deprivation  of  air  even  in  a  minor  degree  may 
be  followed  by  serious  cardiac  depression ;  whereas  with  ether, 
unless  the  patient  be  much  exhausted,  a  moderate  limitation 
of  air  is  not  likely  to  be  attended  by  evil  consequences.  We 
may  speak  of  the  cardiac  depression  which  may  thus  be  in- 
duced as  "  asphyxial  syncope " — a  condition  which  would 
seem  to  depend  upon  an  over-distension  of  the  right  cavities 
of  a  feebly-acting  heart.     With  reference  to  cardiac  failure 


DANGERS    UNDER    ANESTHESIA.  97 

occurring  in  persons  exhausted  by  loss  of  blood,  in  prolonged 
exposure  upon  the  operating-table,  and  in  patients  weakened 
by  previous  disease,  little  need  be  said,  as  the  symptoms  are 
usually  independent  of  the  anesthetic.  The  question  as  to 
the  direct  effect  of  chloroform  upon  the  heart  is  too  complex 
to  be  satisfactorily  discussed  here.  It  may  be  said,  howe\or, 
that  it  is  now  established  as  a  fact  that,  in  the  lower  animals, 
final  arrest  of  the  heart  from  an  overdose  of  chloroform  is 
always  secondary  to  respiratory  failure.  With  reference  to 
nitrous  oxide,  and  to  ether,  when  administered  in  poisonous 
doses,  there  can  be  Uttle  doubt  that  the  cardiac  movements 
continue  till  after  respiration  has  ceased.  Chloroform,  how- 
ever, undoubtedly  lowers  the  action  of  the  heart  after  a  tem- 
porary stimulation,  and  predisposes,  so  to  speak,  to  cardiac 
depression  from  a  variety  of  causes.  Toxic  symptoms  of  a 
poisonous  overdose  of  chloroform  sometimes  manifest  them- 
selves so  rapidly  that  it  becomes  impossible  to  say  when 
cardiac  action  ceases.  The  administrator  should  accustom 
himself  to  observe  the  pulse  as  frequently  as  is  practicable, 
and  this  is  more  especially  necessary  with  chloroform. 
Should  it  become  very  feeble,  slow,  irregular,  or  intermittent, 
the  anaesthetic  must  be  withdrawn  and  fresh  air  freely  ad- 
mitted till  improvement  occurs.  Those  who  recommend  that 
no  attention  should  be  directed  to  the  pulse,  but  that  the 
respiration  only  should  be  watched,  are  not  so  likely  to  obtain 
early  indications  of  approaching  danger  as  those  who  keep  a 
sharp  look-out  for  changes  in  the  character  of  the  pulse.  In 
asthenic,  cachectic,  or  hectic  subjects,  in  patients  suffering  from 
shock,  in  fatty  degeneration  or  other  advanced  affections  of 
the  heart,  and  in  persons  Avho  have  lost  a  considerable  quan- 
tity of  blood  during  the  ojieration,  the  pulse  should  be  care- 
fully watched.  As  already  mentioned,  asthenic  subjects  re- 
quire very  little  of  any  anajsthetic,  and  are  highly  intolerant 
of  any  deprivation  of  air.  Speaking  generally,  should  the 
pulse  gradually  grow  weaker  and  more  rapid,  the  face  and 
lips  paler,  the  extremities  colder,  the  eyelids  fail  to  close — 
symptoms  not  infrequently  met  with  in  prolonged  operations 
upon  weakly  subjects,  the  administrator  should  be  careful  not 
to  keep  his  patient  too  deeply  ansesthetised ;  he  should  see 
that  the  head  is  low  and  that  the  patient  is  kept  as  warm  as 


98  OPERATIVE    SURGERY. 

possible ;  and  he  should  of  course  warn  the  operator  of  the 
patient's  condition.  If,  under  such  chcumstances  as  these, 
completion  of  the  oj^eration  is  urgently  called  for,  an  enema 
(an  ounce  of  brandy  to  two  or  three  ounces  of  warm  water) 
may  be  given  with  advantage  ;  and  cloths  wrung  out  in  very 
hot  water  may  be  applied  to  the  head.  These  measures 
Avill  usually  suffice  to  tide  over  the  remaining  period  of  the 
operation.  If,  however,  the  pulse  should  become  impercept- 
ible at  the  wrist,  and  the  pupils  dilated,  the  operation  should 
be  discontinued,  the  head  lowered,  the  legs  elevated,  a 
broken  capsule  of  nitrite  of  amyl  or  a  cloth  moistened  with 
a  few  drops  of  hq.  ammon.  fort,  held  to  the  nostrils  of  the 
patient.  It  occasionally  happens,  more  especially  with 
chloroform,  that  sjnnptoms  of  cardiac  depression  come 
on  more  suddenly  than  the  j^i'eceding  description  would 
suggest.  Under  such  circumstances  the  anaesthetist  should 
at  once  forcibly  compress  the  lower  ribs  and  proceed  with- 
out delay  to  artificial  respiration  by  Silvester's  method.  He 
should  at  the  same  time  direct  that  the  legs  be  raised  as 
much  as  possible  and  the  head  lowered,  and  a  few  drops  of 
nitrite  of  amyl  administered.  He  himself  should  attend  to 
nothing  save  the  artilicial  respiration.  Cases  of  moderate 
severity  will  usually  yield  to  these  measures  in  a  short  time ; 
but  should  this  not  be  the  case,  artificial  respiration  must  be 
maintained  for  at  least  an  hour.  Sudden  chloroform  syncope 
in  children  may  often  be  successfully  treated  by  merely  in- 
verting the  patient,  but  the  inver.sion  should  as  a  rule  be 
supplemented  by  artificial  respiration. 


99 


part  III. 
LIGATURE   OF  ARTERIES. 

CHAPTER    I. 

General  Considerations. 

History  of  the   Ligature. — The   use   of  the  ligature   as   a 
hasmostatic  dates  from  the  very  earUest  times. 

It  was  advised  by  Celsus,  who  flourished  in  the  first 
century.  "  Tlie  bleeding  vessels,"  he  wrote,  "  are  to  be  taken 
up,  and  two  ligatures  to  be  applied,  one  on  each  side  of  the 
wound,  and  then  to  be  divided  between  the  ligatures." 

It  is  mentioned  by  succeeding  authors — by  Galen  in  the 
second  century,  by  Aetius  in  the  fifth,  by  Rhazes  in  the  tenth. 
Each  writer  quotes  the  authority  of  his  predecessor,  or  sj^eaks 
of  the  procedure  as  emanating  from  Celsus  or  Galen.  In  spite 
of  the  fact  that  some  writers  on  medicine  and  surgery  in  the 
eleventh,  twelfth,  and  thirteenth  centuries  stiU  give  an  account 
of  the  ancient  use  of  the  ligature  as  described  by  Celsus  and 
his  followers,  the  practice  does  not  appear  to  have  become 
general.  In  the  sixteenth  century  at  least  the  securing  of 
arteries  by  hgature  as  a  practical  measure  was  unknown. 
The  bleeding  after  amputation  was  checked  by  styptics, 
"  agglutinatives,"  or  the  actual  cautery,  and  to  Ambrose  Pare 
is  certainly  due  the  credit  of  introducing  the  hgature  definitely 
mto  surgical  practice. 

So  novel  was  Pare's  proposal  that,  although  he  was  familiar 
with  the  use  of  the  ligature  as  described  by  the  ancients,  he 
regarded  his  invention  as  quite  phenomenal.  "  I  thmk  it  was 
taught  me,"  he  writes,  "  by  the  special  favour  of  the  sacred 
Deity;  for  I  learnt  it  not  of  my  masters,  nor  of  any  other, 
neither  have  I  at  any  time  found  it  used  by  any."  This  was 
in  the  year  1564.  This  very  important  element  in  practical 
H  2 


100  OPERATIVE    SURGERY. 

surgery  was  veiy  slowly  accepted.  The  great  English  surgeon, 
Wiseman,  writing  more  than  one  hundred  years  later,  recom- 
mended the  use  of  a  "  royal "  styptic,  or  the  cautery,  in  the 
place  of  the  ligature. 

Sharp,  writing  in  1761,  takes  pains  to  especially  advocate 
the  use  of  the  lisfature  for  the  arrest  of  bleedino:,  because  "  it 
was  not  as  yet  universally  practised  among  surgeons  residing 
in  the  more  distant  counties  (of  England)." 

Antyllus,  who  flourished  in  the  fourth  century,  is  reputed 
to  have  treated  aneurysm  by  first  ligaturing  the  artery  above 
and  below  the  tumour,  and  then  evacuating  the  contents 
of  the  sac.  He  was  careful  to  isolate  the  vein,  and  passed 
the  thread  by  means  of  a  needle  directed  by  a  probe. 

Anel  hgatured  the  brachial  artery  in  1710,  for  a  traumatic 
aneurj'sm  at  the  bend  of  the  elbow,  applying  the  thread  close 
to  the  tumour.  In  December,  1785,  John  Hunter,  after  many 
experiments  and  careful  investigation  of  the  whole  subject, 
hgatured  the  femoral  artery,  in  what  is  now  known  as  Hunter's 
canal,  for  the  cure  of  popliteal  aneurysm. 

From  this  time  dates  the  modern  method  of  treating* 
aneurysm  by  hgature. 

In  the  early  days  of  the  ligature  the  method  known  as 
"  mediate  ligation "  was  employed ;  that  is  to  say,  the  tissues 
surrounding  the  artery  were  also  included  in  the  ligature,  and 
the  vessel  was  thus  compressed  through  the  medium  of  those 
structures.  It  was  Deschamps  who,  in  1797,  first  insisted  that 
the  artery  should  be  weU  and  completely  isolated  before  the 
ligature  Avas  tied,  and  with  him  must  rest  the  credit  of  the 
introduction  of  the  present  method  of  "  immediate  hgation." 

The  introduction  of  catgut  as  a  hgature  material,  by  Sir 
Joseph  Lister,  and  the  employment  of  antiseptic  measures 
in  the  treatment  of  wounds,  has  greatly  modified  the  dangers 
of  the  operation. 

The  silk  ligature  was  left  in  place  until  it  had  cut  through 
the  vessel  Its  extremity  was  allowed  to  hang  out  of  the 
wound.  It  acted  as  a  seton.  Primary  healing  was  not 
possible ;  and  secondary  hsemorrhage,  and  the  evils  attending 
suppuration,  were  quite  common. 

The  use  of  animal  ligatures,  which  could  be  absorbed  in 
due  course  and  which  would  introduce  no  septic  influence 


LIGATURE    OF   AUTERIES.  101 

into  the  wound,  altered  the  aspect  of  the  operation.  The 
animal  ligature  appears  to  have  been  first  introduced  in  1814 
by  Dr.  Physick,  of  Philadelphia.  He  used  Uttle  strips  of 
chamois  leather  which  had  been  rolled  upon  a  slab  until 
they  Avere  hard  and  round.  The  ligature  was  cut  short, 
and  Avas  never  seen  again  in  those  wounds  which  healed 
by  first  intention.  These  ligatures  appear  to  have  been  em- 
ployed in  the  United  Kingdom  together  with  other  experimental 
forms  of  animal  ligature.  Sir  Astley  Cooper  tied  the  femoral 
successfully  with  catgut,  while  Dr.  McSweeny,  of  Cork,  re- 
commended silkworm  gut.  Silk  was,  however,  the  regular 
material  employed,  until  Lister  definitely  introduced  catgut, 
and  estabUshed  the  properties  and  determined  the  prepara- 
tion of  that  substance. 

The  materials  more  recently  introduced  are  ligatures  of  ox 
aorta  and  of  kangaroo  tendon. 

A  very  valuable  contribution  to  the  history  of  this  subject 
is  afforded  by  Mr.  Holmes  in  the  British  Medical  Journal  for 
November  15  th,  1890. 

Instruments  required. — The  follo^ving  is  the  list : — 1, 
Scalpel ;  2,  two  pairs  of  dissecting  forceps ;  3,  wound  hooks ; 
4,  retractors ;  5,  long  toothed  forceps ;  6,  pressure  forceps ;  7, 
aneurysm  needle ;  8,  ligature ;  9,  artificial  light. 

1.  The  scalpel  should  be  small,  and  of  the  pattern  already 
described.  A  stout  instrument  may  be  used  for  the  skin 
incision,  a  finer  for  opening  the  sheath. 

2.  The  tissues  are  often  very  conveniently  divided  between 
two  pairs  of  dissecting  forceps,  one  pair  being  held  by  an 
assistant. 

3.  Small  blunt  hooks,  with  long  shafts,  are  most  con- 
venient as  retractors,  especially  to  draw  nerves  and  tendons 
out  of  the  way.  Their  use  is  well  illustrated  in  the  operation 
for  securing  the  lingual  artery. 

4.  Good  retractors  are  needed  when  deeply-seated  vessels 
are  concerned.  In  securing  the  iliac  arteries  especially, 
broad  copper  spatuke  and  large  rectangular  retractors  are  of 
use. 

5.  The  sheath  may  be  in  most  cases  quite  conveniently 
picked  up  by  ordinary  dissecting  forceps.  In  the  case  of  deep- 
seated  arteries,  however,  longer,  finer,  and  neater  instruments 


102  OPERATIVE    SUEGEBY. 

are  required,  and  of  these  the  finely-toothed  forceps  are  the 
most  convenient. 

Specially  long  forceps  are  needed  for  securing  the  ihac 
arteries. 

6.  As  the  wound  must  be  as  bloodless  as  possible,  pressure 
forceps  are  very  necessary.  If  the  bleeding  vessel  be  carefully 
picked  up,  and  the  forceps  be  allowed  to  remain  long  attached, 
the  haemorrhage  will  usually  be  checked  without  the  need  of  a 
hgature. 

7.  The  aneurysm  needle  must  be  well  made  and  well 
polished.  It  need  not  be  too  fine.  In  deahng  with  large 
and  deeply-placed  arteries,  a  very  strong  needle  is  required. 
In  James's  case  of  hgature  of  the  abdominal  aorta  the  needle 
broke  at  its  handle,  the  surgeon  "  httle  anticipating  occasion 
for  so  much  force."  Needles  are  not  infrequently  met  with 
made  of  such  indifferent  metal  that  they  bend  under  a  not 
unreasonable  strain. 

The  ordinary  needle  (Fig.  21),  in  which  the  curve  is  simple, 


Fig.    21. — ANEUETSM   NEEDLE. 


and  in  which  the  plane  of  the  handle  is  at  right  angles  to  the 
plane  of  the  blade,  answers  very  well  in  most  cases.  It  appears 
to  have  been  devised  by  Saviard  towards  the  end  of  the  seven- 
teenth century.      The  instrument   known  as   Syme's   needle 


r~ 


Fig.    22.  — SVMKS   ANEURYSM    NEEDLE. 


(Fig.  22),  in  which  the  "flat"  of  the  handle  and  of  the  steel 
are  on  the  same  plane,  is  preferred  by  many. 

For   not   a   few   deeply-seated   arteries   the   doubly-bent 
needle  of  Dupuytren  (Fig.  23)  is  of  great  service,  if  not,  indeed, 


LIGATURE    OF    ARTERIES.  103 

essential.  The  curved  part  of  the  needle  is  here  bent  laterally, 
and  is  at  right  angles  to  the  long  axis  of  the  handle.  There 
are  two  forms  of  this  needle — one  bent  to  the  right,  and  the 
other  to  the  left. 

8.  The  best  ligature  material  on  the  whole  is  ehromicised 
catgut.  It  must  be  of  rehable  make,  be  strong,  round,  quite 
lissome,  of  uniform  thickness,  and  per- 
fectly smooth.  The  size  must  be 
regulated  by  the  dimensions  of  the 
vessel  to  be  tied. 

There  is  no  especial  advantage  in 
the  use   of  very  thick   catgut.      The        ^ig.  23.-dupuytken'.s 

•^     .  '^  ANEURYSM  NEEDLE. 

ligature  to  be  applied  should  always 

be  selected  with  great  care  and  well  tested. 

It  should  be  allowed  to  soak  for  ten  minutes  or  so  in 
carbolised  water,  and  should  then  be  again  examined  and 
tested.  It  must  be  long  en;  ugh  to  be  easily  manipulated. 
Mr.  Holmes  prefers  a  ligature  of  kangaroo  tendon  to  one  of 
catgut,  on  the  ground  that  the  latter  material  is  not  always  of 
quite  reliable  composition. 

Mr.  Hohnes  has  given  an  admirable  review  of  the  different 
forms  of  ligature  in  the  paper  already  named. 

On  the  subject  of  the  tendon  ligature  a  paper  by  Mr.  Dent 
{Med.  Chir.  Trcm%,  Vol.  LXIV.)  may  also  be  consulted.  (For 
a  consideration  of  the  flat  ligature,  see  "Ligature  of  the 
Innominate  Artery.") 

9.  In  the  exposure  of  deeply-placed  vessels  a  good  light 
in  the  depths  of  the  wound  is  essential.  This  may  be  obtained 
by  means  of  a  reflector,  or,  better  still,  by  the  use  of  a  small 
portable  electric  lamp. 

Position  of  the  Patient. — The  position  of  the  patient  wiU 
vary  a  little  according  to  the  artery  to  be  tied.  In  general 
terms,  it  may  be  said  that  the  surgeon  should  stand  upon  the 
side  to  be  operated  on,  and  that  the  incision  on  the  right  side 
is  more  conveniently  made  from  above  downwards,  and  on  the 
left  side  from  below  upwards.  The  chief  assistant  stands 
opposite  to  the  surgeon,  and  has  for  his  principal  duty  the 
sponging  and  the  retraction  of  the  parts  of  the  wound. 

The  Steps  of  the  Operation. — These  will  be  considered  in 
the  foUowincp  order : — 


104  OPERATIVE    SURGERY. 

1.  The  line  of  the  artery. 

2.  The  incision.  , 

3.  The  exposure  of  the  artery. 

4.  The  opening  of  the  sheath. 

5.  The  passing  of  the  hgature. 

1.  The  Line  of  the  Artery. — This  hne  must  be  very  accu- 
rately defined.  It  may  differ  from  what  is  commonly  given 
as  the  anatomical  line  of  the  vessel. 

For  example,  the  course  of  the  ulnar  artery  is  said  to 
be  represented  by  a  Ime  drawn  from  the  middle  of  the  bend 
of  the  elbow  to  the  radial  side  of  the  pisiform  bone.  This  hne 
scarcely  touches  the  artery,  however,  q,t  any  one  point.  The 
surgical  hne  for  the  lower  two-thirds  of  the  vessel — the  part 
upon  which  a  ligature  may  be  applied — is  represented  by  a 
line  dra-wn  from  the  tip  of  the  internal  condyle  to  the  radial 
side  of  the  pisiform. 

The  posture  of  the  limb,  also,  is  of  moment.  In  indicating 
the  exact  situation  of  the  femoral  or  brachial  arteries,  for 
instance,  it  is  essential  that  the  limb  should  be  placed  in 
a  certain  position  before  the  line  is  drawn. 

The  size  of  the  artery  should  be  realised.  In  the  sections 
which  foUow,  the  dimensions — as  given  by  Quain — are  noted 
in  connection  with  each  vessel. 

The  operator  should  also  be  aware  of  the  possible  variations 
of  the  artery  to  be  exposed. 

2.  The  Incision. — The  incision  should — when  possible — 
be  so  placed  upon  the  line  of  the  artery  as  to  avoid  superficial 
veins.  It  is  most  desirable  that  there  should  be  little  bleed- 
ing during  the  operation,  that  the  Avound  should  be  "dry," 
and  the  view  of  the  depths  not  embarrassed  by  pressure 
forceps. 

The  scalpel  should  be  held  in  what  is  termed  the  dinner- 
knife  position.  (>S'ee  Fig.  13,  page  51.)  The  cut  should  be  freely 
made  and  cleanly  cut.  There  is  a  disposition  to  make  the 
wound  too  small.  A  small  wound  carries  with  it  special 
dangers  and  difticulties,  whereas  a  little  increase  in  the  length 
of  the  skin-cut  does  not  add  to  the  gravity  of  the  procedure. 
It  is  frequently  adduced  as  a  demonstration  of  skill,  that  such 
and  such  an  artery  has  been  ligatured  through  an  incision  oi 
unusually  small  dimensions.     These  exhibitions  of  dexterity 


LIGATURE    OF   ARTERIES.  105 

are  only  suited  for  the  deadhouse.  While  the  incision  should 
not  be  one  line  longer  than  is  possible,  it  should  be  long  enough 
to  enable  the  artery  to  be  reached  and  exposed  with  ease  and 
safety.  The  experimenter  on  the  cadaver,  who  ties  the 
common  carotid  through  an  inch  incision,  not  improbably 
includes  the  vagus  nerve  in  his  ligature. 

The  knife  should  be  entered  at  right  angles  to  the  surface, 
and  should  be  in  the  same  position  when  ^vithdrawn.  The 
surface  wound  should  be  of  equal  depth  throughout.  There 
should  be  no  "  tails  "  to  the  cut. 

The  skin  should  be  steadied  with  the  left  hand  while 
the  integuments  are  being  divided. 

After  the  surface  cut  has  been  made,  the  next  step  is  to 
divide  the  deep  fascia,  or  aponeurosis.  This  is  done  by  a  clean 
cut  made  in  the  line  of  the  original  incision,  and  carried  the 
whole  length  of  the  wound. 

A  director  is  not  required  either  at  this  or  any  other  stage 
of  the  operation.  In  the  ligature  of  arteries  the  director  should 
be  avoided  as  an  unnecessary  and  dangerous  weapon.  (See 
page  53.) 

When  the  deep  fascia  has  been  exposed  in  a  limb,  the  out- 
lines of  the  underlying  muscles  and  tendons  are  rendered  more 
or  less  distinct.  A  gap  between  two  adjacent  muscles  has 
usually  to  be  followed  in  the  operation.  This  gap  is  very 
commonly  said  to  be  indicated  by  a  white  or  a  yellow  line. 
The  "yellow  line"  is  due  to  the  fat  occupying  the  hollow 
between  the  muscles,  and  is  not  seen  in  wasted  subjects ;  nor 
is  it  clear  in  the  cadaver,  nor  in  a  hmb  which  has  been 
deprived  of  blood  by  Esmarch's  band. 

The  "  white  Une  "  is  almost  equally  deceptive ;  it  depends 
upon  a  thickening  of  the  fascia  itself,  due  to  the  attachment 
of  an  inter-muscular  septum.  In  hgaturing  the  uhiar  artery 
in  the  forearm,  the  operator  is  instructed  to  seek  for  "  the 
white  tendinous  margin  of  the  jflexor  carpi  ulnaris."  That 
white  margin  has  no  real  existence,  nor  is  a  "  white  line  "  in 
the  fascia  by  any  means  constant  in  this  position.  (See  the 
section  on  the  ligature  of  this  artery.)  In  cutting  down  upon 
the  upper  third  of  the  anterior  tibial  artery  also,  the  "  white 
line"  which  is  supposed  to  guide  the  surgeon  to  that  vessel 
ha.s  a  very  uncertain  existence,  as  is  pointed  out  in  the  account 


106  OPEliATIVE    SURGERY. 

of  that  operation.  Not  infrequently  the  gap  between  the 
muscles  is  indicated  by  an  inter-muscular  artery. 

The  interval  is  best  sought  by  the  sense  of  touch  and 
by  the  left  index  finger.  A  highly-educated  left  index  linger 
is  the  most  valuable  factor  in  the  performance  of  any  operation 
for  the  Hgation  of  an  artery. 

The  space  is  to  be  felt  when  it  cannot  be  seen,  and  the 
artery  itself  is  often  more  surely  to  be  recognised  by  the  finger 
than  by  the  eye.  Farabeuf  well  says : — "  C'est  done  les  yeux 
en  I'air  et  le  doigt  dans  la  plaie  qu'il  s'habituera  k  Uer  certaines 
arteres,  une  fois  les  incisions  superficielles  accomplies."  It  is 
especially  when  the  parts  are  uniformly  obscured  by  blood 
that  the  value  of  a  practised  forefinger  is  appreciated. 

The  muscular  interspace  is  best  opened  with  the  handle  of 
the  scalpel  or  with  the  linger.  No  attempt  should  be  made 
to  demonstrate  it  by  the  edge  of  the  scalpel.  Dissection  is 
here  out  of  place.  The  narrow  and  obscure  tract  of  connec- 
tive tissue  that  leads  down  to  the  artery  is  better  followed  by 
the  sensitive  finger  than  by  any  sharp  instrument.  And  here 
again  Farabeuf  advises  well : — "  Mais  il  aurait  tort  de  ne  pas 
se  servir  du  doigt,  du  seul  index  gauche,  delicatement  utilise, 
non  de  tous  les  doigts  des  deux  mains,  comme  le  font  certains 
maladroits  dont  le  faire  devient  ainsi  malpropre,  brutal  et 
grossier.  Sans  le  toucher,  la  hgature  d'une  artere  devient 
le  plus  souvent  une  vaste  dissection ;  ce  n'est  plus  une  opera- 
tion k  traumatisme  limite." 

In  opening  up  the  depth  of  the  wound  the  posture  of  the 
Umb  may  be  so  altered  as  to  relax  the  muscles  about  the 
incision.  It  is  better  that  this  should  not  be  done  until  the 
interspace  has  been  well  and  clearly  demonstrated. 

The  deej)  part  of  the  wound  should  follow  the  line  of 
the  superficial  incision,  and  should  equal  it  in  extent.  The 
wound  should  not  be  funnel-shaped. 

Retractors  must  be  freely  used.  Every  means  must  be 
adopted  to  expose  the  depths  of  the  wound  clearly.  All 
bleeding  must  be  checked  as  it  is  encountered.  Small  pieces 
of  the  finest  Turkey  sponge  should  be  employed  to  sponge 
the  wound  and  to  keep  it  dry  to  its  very  bottom.  In  effect- 
ing this  end  the  part  can  often  be  so  inclined  that  blood  tends 
to  flow  from  the  wound  by  gravitation  rather  than  into  it. 


LIGATURE    OF   ARTERIES.  107 

Above  all  things,  the  operation  must  be  conducted  step  by- 
step.  Each  guiding  point  must  be  well  made  out  before  the 
next  point  is  sought  for.  This  circumstance  is  well  illustrated 
by  the  operation  for  securing  the  lingual  artery. 

3.  The  Exjwsure  of  the  Artery. — The  artery  should  be 
sought  for  with  the  fingfer.  As  the  tissues  will  be  more  or 
less  evenly  stained  with  blood,  the  linger — in  a  deep  wound 
especially — aftbrds  the  best  means  of  differentiating  the  artery, 
the  veins,  and  a  companion  nerve. 

To  the  touch  the  nerves  feel  firm,  resisting,  round,  and 
cord-Hke.  They  cannot  be  flattened  by  the  pressure  of  the 
finger.  The  veins  greatly  exceed  the  corresponding  arteries 
in  size.  They  often  overlap  these  vessels.  They  feel  soft  and 
yielding,  and  thin- walled.  They  are  easily  compressed,  and 
when  so  treated  swell  out  upon  the  distal  side.  When  the 
finger  touches  the  compressed  vein  the  vessel  as  a  tube  can 
scarcely  be  appreciated.  In  this  respect  it  is  very  different 
from  the  artery.  The  artery  feels  firmer  and  more  elastic.  It 
is  not  unlike  a  thin  indiarubber  tube  to  the  touch.  It  is 
movable,  and  often  shps  about  under  the  finger  in  a  charac- 
teristic manner.  It  can  be  compressed,  but  not  so  readily  as 
the  vein.  When  flattened  out  by  the  finger,  an  artery  of 
moderate  dimensions  feels  like  a  flat  band  or  thong,  thick  and 
elastic,  and  hollowed  out  a  little  in  the  centre,  so  that  the 
margins  feel  thicker  than  the  median  part.  Above  all,  it 
pulsates. 

There  are  many  fallacies  in  this.  The  pulsations  of  the 
artery  may  be  transmitted  to  the  nerve  (as  in  the  case  of  the 
median  nerve  and  the  brachial),  or  to  the  companion  vein. 
When  the  patient  is  under  an  anesthetic,  and  when  the  pulse 
is  feeble,  or  very  rapid,  the  movement  in  the  artery  may  be 
diriicult  to  detect.  If  an  aneurysm  or  pulsating  growth  exist, 
compression  of  the  artery  causes  the  pulsation  in  the  tumour 
to  cease. 

The  artery  when  exposed  is  often  found  much  contracted. 
It  looks  so  much  smaller  than  was  expected,  that  it  may,  in 
such  case,  be  mistaken  for  an  abnormal  vessel. 

In  the  matter  of  the  appearance  of  the  tissues,  the  depth 
of  the  woimd — which  is  often  great — and  the  even  tinting  of 
the  parts  with  blood,  render  an  inspection  of  less  value  than 


108  OPERATIVE    SUEGEBY. 

an  examination  with  the  finger.  When  the  wound  is  well 
opened  up  the  nerves  stand  out  as  clear,  lou  ided,  white  cords; 
the  vehis  are  of  a  purple  colour,  and  of  somewhat  uneven  and 
wavy  contour  ;  the  artery  is  regular  in  outline,  and  is  of  a  pale 
pink  or  pinkish-yellow  tint,  the  large  vessels  being  of  Hghter 
colour  than  the  small. 

There  may  be  one  companion  vein  or  two — the  venon 
cmnites.  All  arteries  below  the  knee  are  accompanied  by 
venae  comites.  All  arteries  of  the  arm,  forearm,  and  hand  are 
attended  in  Hke  manner. 

The  arteries  of  the  trunk,  which  are  of  small  or  of  medium 
size,  are  for  the  most  part  accompanied  by  venas  comites ;  such 
are  the  pudic,  the  deep  epigastric,  the  deep  circumflex  iliac, 
and  the  internal  mammary. 

The  arteries  in  the  head  and  neck  are  attended  by  single 
veins,  the  only  noteworthy  exception  to  this  being  the  Hngual 
arter}^ 

The  vense  comites  He  close  to  the  artery,  one  upon  each 
side  of  it.  They  are  apt  to  communicate  with  one  another 
freely  across  the  vessel  by  means  of  many  transverse  branches. 
When  the  artery  is  placed  between  muscles  which  lie  the  one 
in  front  of  the  other — as  is  the  case  with  the  posterior  tibial 
artery — the  companion  veins  lie  one  on  each  side  of  the 
single  trunk.  When,  however,  the  muscular  interspace  is 
antero-posterior,  as  is  the  gap  between  the  tibialis  anticus  and 
the  extensor  communis  digitorum,  in  which  the  anterior  tibial 
artery  Hes,  the  veins  are  placed  so  that  one  is  in  front  of  the 
artery  and  the  other  behind  it. 

4.  The  Opening  of  the  Sheath. — The  artery  is  now  reached. 
It  remains  to  open  the  sheath,  and  to  clear  a  part  of  the 
vessel  for  the  passage  of  the  aneurysm  needle. 

The  sheath  must  be  opened  with  the  scalpel  with  infinite 
care  and  the  most  dehcate  precision.  The  knife  must  have  a 
perfect  cutting  edge.  A  good  hght  is  essential,  and  a  pair  of 
trustworthy  forceps  by  means  of  which  it  is  possible  to  pick 
up  a  fine  fold  of  tissue,  and  hold  it  firmly. 

The  sheath  is  picked  up  over  the  centre,  or  median  part, 
of  the  artery,  in  the  form  of  a  fold  which  is  transverse  to  the 
long  axis  of  the  vessel  It  must  be  picked  up  cleanly  and 
entirely.     It  is  unwise  to  pick  up  a  longitudinal  fold.     In  the 


LIGATURE    OF   ARTERIES.  109 

first  place,  such  a  fold  is  not  so  easily  grasped  nor  so  readily 
raised  from  the  vessel,  and,  in  the  second  place,  the  forceps 
may  catch  up  at  the  same  time  a  longitudinal  fold  of  the 
subjacent  arterial  coat,  or  even  of  one  of  the  veins. 

The  transverse  fold  of  the  sheath  is  then  incised.  The 
cut  should  be  clean,  should  be  mavle  in  the  long  axis  of  the 
artery,  and  over  the  centre  of  the  vessel.  In  length  it  should 
be  from  5  to  10  m.m. 

When  the  sheath  has  been  well  divided,  the  serous-like 
space  between  it  and  the  artery  becomes  at  once  evident. 

Before  the  incision  is  made,  the  point  of  the  forcej^s  may 
be  moved  a  little  to  and  fro,  to  ensure  the  freedom  of  the  part 
which  is  held  from  any  deep  attachments.  The  sheath  may 
in  this  way  be  really  identified. 

The  blade  of  the  scalpel  should  be  inclined  obliquely,  i.e., 
with  the  flat  of  the  knife  towards  the  artery. 

The  fold  of  the  sheath  must  be  held  well  up  during  the 
making  of  the  incision.  When  once  a  good  hold  of  the  sheath 
has  been  obtained  by  the  forceps  the  instrument  must  not 
be  shifted. 

In  this  part  of  the  operation  a  director  is  not  only  useless 
but  dangerous.  The  opening  of  the  sheath  with  a  blunt  in- 
strument is  a  proceeding  which  does  not  belong  to  the 
surgery  of  the  present  age. 

The  method  of  picking  up  the  sheath  with  tAvo  pairs  of 
forceps  (one  of  which  is  held  by  an  assistant),  and  then  of 
cutting  between  the  two  blades,  is  cumbrous,  inconvenient,  and 
not  without  danger. 

5.  Tlte  Passing  of  the  Ligature. — The  original  hold  of  the 
forceps  upon  the  sheath  should  not  be  relaxed.  The  surgeon 
now  takes  the  aneurysm  needle  in  his  right  hand,  and  intro- 
duces its  unthreaded  point  between  the  artery  and  the  sheath 
for  the  purpose  of  clearing  the  former.  The  needle  should  be 
held  with  its  concavity  towards  the  vessel,  and  it  should  be 
gently  insinuated  about  half-way  round  the  artery,  being 
passed  under  that  part  of  the  sheath  held  up  by  the  forceps. 

The  sheath  upon  the  opposite  side  of  the  incision  should 
now  be  taken  up  with  the  forceps,  and  the  needle  be  passed 
beneath  the  vessel  so  as  to  clear  the  remaining  portion — the 
deep  part — of  its  surface.     The  needle  will  soon  emerge  in  the 


110  OPERATIVE    SURGERY. 

wound  upon  the  opposite  side  of  the  arteiy,  when  it  should 
be  threaded,  and  be  then  withdrawn,  carrying  the  Hgature 
Avith  it. 

About  one  centimetre  of  the  artery  more  or  less  is  cleared. 
The  needle  should  be  kept  throughout  at  right  angles  to  the 
Une  of  the  vessel.     It  should  never  be  passed  threaded. 

It  is  the  usual  practice  to  pass  the  needle  fi'om  the  vein. 
A  more  important  rule  is  to  pass  the  needle  from  the  forceps. 

It  is  often  more  convenient  to  pass  it  towards  the  vein. 
If  the  sheath  has  been  well  opened,  and  a  way  for  the  ligature 
carefully  cleared  around  the  artery,  there  can  be  little  excuse 
for  forcing  the  point  of  the  needle  through  the  sheath  into 
the  companion  vessel 

If  a  large  vein  he  wounded,  the  practice  advised  by 
Air.  Jacobson  ("  The  Operations  of  Surgery,"  page  986)  in 
the  case  of  wound  of  the  femoral  vein  during  the  Hgaturing 
of  the  artery  should  be  carried  out.  "The  surgeon  must 
not  persist  in  his  attempt  to  tie  the  artery  at  the  spot, 
a  course  which  will  only  end  in  his  inflicting  more  injury 
on  the  vein ;  but  finger-pressure  being  made  on  the  lower 
angle  of  the  wound,  the  artery  is  tied  either  above  or  below 
the  spot  where  the  vein  has  been  injured.  As  soon  as  the 
artery  is  secured  no  further  haemorrhage  will  take  place,  but 
pressure  may  be  kept  up  b}'  means  of  a  carbolised  sponge 
over  the  wound  for  a  day  or  two."  A  small  puncture  in  a 
large  vein  may  usuall}'-  be  safely  closed  by  picking  up  the 
wounded  part  of  the  waU  and  passing  a  fine  catgut  ligature 
around  it,  as  one  would  tie  up  a  hole  in  a  bag. 

When  venae  comites  attend  a  deep  artery  of  moderate  size, 
such  as  the  ulnar  or  posterior  tibial,  much  time  may  be 
wasted  and  damage  done  by  a  determined  attempt  to  separate 
the  artery  from  the  veins.  This  is  especially  the  case  when 
many  transverse  connecting  branches  pass  across  the  artery. 
In  such  instances  practice  has  shoAvn  that  no  evil  results  from 
including  the  two  veins  in  the  ligature.  In  dealmg  with  still 
smaller  arteries,  such  as  the  lingual,  no  attempt  is  made  to 
avoid  including  the  companion  veins  in  the  ligature. 

It  is  needless  to  say  that  the  greatest  care  must  be  taken 
to  avoid  including  a  nerve  in  the  ligature.  If  the  sheath  be 
well  opened,  and  the  needle  be  kept  close  to  the  artery  and 


LIGATURE    OF   ARTERIES.  Ill 

be  passed  round  with  ease,  there  is  little  danger  of  includ- 
ing a  nerve. 

The  catgut  passed  around  the  artery  should  have  been 
rendered  pliable  by  a  short  immersion  in  a  weak  carbolic 
solution. 

The  ligature  should  be  passed  and  be  tied  exactly  at  right 
angles  to  the  line  of  the  artery.  The  knot  should  be  tied 
quietly  and  slowly,  and  not  with  a  vicious  jerk. 

It  should  be  sufficiently  tight  to  rupture  the  inner  coats. 
Care  should  be  taken  that  the  vessel  is  not  dragged  out  of 
place  in  the  tying. 

The  points  of  the  two  forefingers  should  meet  upon  the 
artery  as  the  knot  is  being  tied,  and  the  final  strain  upon  the 
ligature  should  be  given  by  placing  the  terminal  knuckles  of 
these  two  fingers  in  contact  and  using  them  as  the  fulcrum 
of  a  lever. 

Messrs.  Ballance  and  Edmunds  have  shown  {Med.-Chir. 
Trans.,  Vol.  Ixix.)  that  it  is  not  strictly  necessary  for  success  in 
obliterating  arteries  to  divide  the  inner  coats.  Mr.  Holmes, 
hoAvever,  after  an  elaborate  criticism  of  this  point  in  the  papei- 
already  alluded  to,  considers 
that  it  is  safer  and  better  to  tie 
the  arteiy  tightly. 

The  knot  should  be  a  reef- 
knot  (Fig.  24),  not  a  "  granny." 
The  double-hitch,  or  surgical  ^ig.  24.-The^  Figure  to  the  right 
knot,  is  not  suitable,  more  f  1^°'^^''^  ^  ^%f  ^^^^^  ^^^^  to  the  left  a 
especially  when  catgut  is   em- 

plo3'ed.  With  this  material  it  may  be  found  to  be  impossible 
or  very  difficult  to  tighten  the  knot  about  the  artery.  More- 
over, the  knot  when  made  with  catgut  fomis  a  considerable 
mass,  and  is,  at  the  best,  a  clumsy  method  of  occluding  the 
vessel. 

The  reef-knot,  if  well  tied,  will  not  fail 

The  practice  of  applying  a  double  ligidure  to  the  artery, 
and  of  dividing  the  vessel  between  them,  has  been  revived 
from  time  to  time  since  Celsus  advised  it.  Aberncthy  re- 
introduced the  practice  in  1797,  and  was  strongly  in  favour 
of  it,  as  also  were  Sedillot,  Mannoir,  Cline,  and  others. 
Seco?^dary  haemorrhage  was  observed  to  be  much  less  common 


112  OPERATIVE    SUEGEEY. 

after  amputation  than  it  was  after  the  apphcation  of  a  Hgature 
for  aneurysm,  and  it  was  beheved  that,  by  applying  a  double 
hgature  and  dividing  the  vessel  between,  this  tendency  would 
be  lessened.  The  question  is  thus  reviewed  by  MacCormac : — 
"The  artery  is  able  to  retract  somewhat  on  each  side  after 
division,  the  tension  is  lessened,  and  its  condition  in  conse- 
quence resembles  that  of  a  vessel  tied  on  the  face  of  a 
stump.  The  artery,  too,  under  these  circumstances,  may  be 
tied  nearer  to  its  undisturbed  connections,  a  practice  which  it 
may  be  well  to  adopt  in  cases  where  an  unhealthy  wound 
already  exists,  and  where  the  patient's  general  condition  is 
such  as  to  render  primary  union  of  the  wound  improbable. 

"  The  safety  and  greater  facihty  of  employing,  as  a  rule, 
only  a  single  hgature,  are,  however,  amply  demonstrated  by 
experience,  and  the  advantages  of  the  other  method  are  not 
so  considerable  as  to  lead  to  its  general  adoption.  In  cases 
where  the  artery  lies  deeply,  where  the  external  wound  is 
comparatively  small,  and  where  surrounding  structures  are 
important  and  space  hmited — as,  for  instance,  near  to  the  iliac 
arteries,  the  innominate,  or  the  subclavian  artery — it  may  be 
quite  impossible  to  isolate  the  vessel  sufficiently  to  apply  two 
ligatures  and  divide  the  artery  between  them.  It  will  also  be 
more  difficult  to  discover  the  end  of  the  divided  artery  if 
secondary  haemorrhage  ensue.  The  presence  of  a  lateral 
branch  may  hkewise  occasion  serious  embarrassment,  or 
render  double  ligature  impracticable."  Mr.  Holmes  considers 
that  Abernethy's  proposal  is  "  a  step  backwards." 

The  After-Treatment. — The  superficial  wound  is  closed  by 
sutures,  and  dressed  in  the  usual  way.  No  drainage-tube  is 
required. 

In  the  case  of  the  main  artery  of  one  of  the  extremities, 
the  hmb  should  be  kept  absolutely  at  rest,  and  be  a  httle 
raised.  The  arm  would  He  outstretched  upon  a  pillow,  the 
lower  limb  would  be  raised  upon  an  inclined  plane.  The 
whole  extremity  is  enveloped  in  cotton  wool,  and  is  kept  warm 
by  hot  bottles.  In  the  case  of  the  ligature  of  vessels  of  the 
size  of  the  iliacs,  the  subclavian,  or  the  common  femoral, 
absolute  rest  shoidd  be  enforced  for  a  period  of  not  less  than 
twenty-one  days. 

The  time  involved  in  the  after-treatment  of  cases  in  which 


LIGATURE    OF   ALiTERIES.  113 

smaller  vessels  have  been  ligatured  may  be  regulated  in  pro- 
portion. The  period  of  coni})ulsory  rest  should  be  longer  in 
old  subjects  than  in  the  young,  and  in  cases  in  which  the 
lower  limb  is  concerned  than  in  the  upper. 

In  the  chapters  which  follow,  the  operation  for  the  Hgat' ire 
of  the  chief  arteries  which  come  within  the  field  of  surgery  is 
described. 

Xo  attempt,  however,  has  been  made  to  give  an  account 
of  every  operation  of  this  kind  which  might  possibly  be 
carried  out.  The  operations  upon  the  smaller  arteries  are  per- 
formed to  arrest  or  to  prevent  hiemorrl  'ige ;  the  circumstances 
of  such  operations  are  simple,  are  influenced  mainly  by  the 
condition  of  the  wound  or  injur}",  and  need  no  detailed 
description.  Almost  every  minor  artery  in  the  body  has  been 
at  one  time  or  another  secured,  but  the  simple  anatomical 
conditions,  and  the  common  surgical  principles  involved  in 
these  procedures,  would  not  justify  a  systematic  description  in 
each  instance. 

The  average  dimensions  of  each  of  the  larger  arteries,, 
such  as  the  subclavian  and  the  iliacs,  are  given  in  the  account 
of  the  anatomy  of  the  vessel.  The  calibre  of  arteries  of  or 
below  the  size  of  the  common  carotid  is  expressed  by  a 
Roman  figure  after  the  name  of  the  vessel  {e.g.,  Posterior 
Tibial,  iii.).  This  refers  to  one  of  the  six  orders  into  Avliich 
Henle  divided  these  vessels  according  to  their  average  cahbre. 

These  orders  are  as  follows,  and  are  thus  arranged  in 
Quain's  "  Anatomy  "  : — 


Order. 

Avei-aga  Calibre. 

Example. 

I. 

8  in.m.  (i  inch). 

Common  carotid. 

11. 

6  m.m.  {\  inch). 

Brachial. 

III. 

5  m.m.  (i  inch). 

Ulnar. 

IV. 

3-5  m.m.  (i  inch). 

Lingual. 

\. 

2  m.m.  (i*2  inch). 

Posterior  Auricular. 

VI. 

1  to  "5  m.m.  (Ji;  to  J^g  i 

inch). 

Supra-orbital. 

114 


CHAPTER    II. 

Ligature  of  the  Arteries  of  the  Upper  Limb, 
the  radial  artery  (iv.). 

Anatomy. — The  radial  artery  continues  the  line  of  the 
brachial,  and  although  it  is  smaller  than  the  ulnar,  must  be 
regarded  morphologically  as  the  main  artery  of  the  forearm. 

The  relations  of  that  part  of  the  vessel  only  which  hes  in 
the  forearm  will  here  be  considered.  (For  the  anatomy  of 
the  artery  in  the  "  tabatiere  anatomique,"  see  page  117.) 

The  radial  follows  a  nearly  straight  course  from  the  bifurca- 
tion of  the  brachial  artery — opposite  the  neck  of  the  radius 
— to  the  inner  side  of  the  styloid  process  of  that  bone. 

The  upper  half  of  the  artery  is  covered  by  the  muscular 
mass  of  the  supinator  longus,  the  lower  half  by  the  skin  and 
fascia  only.  The  supinator  longus  muscle  becomes  tendinous 
about  the  middle  of  the  forearm. 

The  vessel  has  behind  it,  in  order  from  above  downwards, 
the  biceps  tendon,  supinator  brevis,  insertion  of  pronator  teres, 
radial  origin  of  flexor  subhmis,  flexor  longus  poUicis,  pronator 
quadratus,  and  the  lower  end  of  the  radius.      ^ 

Vense  comites — connected  by  many  transverse  branches — 
accompany  the  artery,  one  lying  upon  each  side  of  the 
vesseL 

The  radial  nerve  is  only  in  direct  relation  with  the  artery 
in  the  middle  third  of  the  forearm.  It  here  lies  to  its  outer 
side.  In  the  upper  third  of  the  limb  the  nerve  is  at  a  con- 
siderable distance  from  the  artery,  while  some  three  inches 
above  the  wrist  it  leaves  the  vessel  altogether  to  pass  beneath 
the  supinator  longus  tendon  to  the  back  of  the  hand. 

Line  of  the  Artery. — A  hne  from  the  centre  of  the  bend 
of  the  elbow,  to  the  gap  between  the  scaphoid  bone  and  the 
tendons  of  the  extensor  ossis  and  extensor  pi-imi  internodii 
pollicis. 


LIGATURE    Ob'    L'ADIAL    ARTERY. 


115 


Indications. — The  urtories  of  the  forearm — radial  and 
ulnar — are  not  frequently  ligatured;  the  circumstances  which 
usually  call  for  ligature  are  wound  and  traumatic  aneurysm. 

Position. — The  surgeon  stands  upon  the  side  to  be 
oi^erated  on.  The  hmb  is  in  the  position  of  supination,  and 
is  tirmty  held  by  an  assistant,  who  grasps  it  by  the  hand  and 
by  the  upper  arm.  The  incision  on  the  right  side  should  be 
made  from  above  downwards ;  on  the  left  side  it  is  con- 
veniently made  in  the  opposite  direction. 

1.  Ligature  in  the  Lower  Third  of  the  Forearm. 

Operation. — An  incision  about  one  inch  and  a  quarter  in 
length  is  made  over  the  line  of  the 
pulse,  midway  between,  and  parallel 
with,  the  tendons  of  the  supinator 
longus  and  flexor  carpi  radiahs 
muscles.  The  cut  must  not  reach 
below  the  level  of  the  tuberosity  of 
the  scaphoid  (Fig.  25). 

The  commencement  of  the  super- 
ficial radial  vein  usually  Hes  over 
the  artery  in  this  situation,  and  im- 
mediately under  the  skin.  It  should 
be  avoided. 

The  fascia,  which  is  here  quite 
thin,  is   divided  in  the  line   of  the 


orioinal  wound.      The 


between 


^&—  ~  ,  —  gap 
the  two  tendons  is  now  made  mani- 
fest. Over,  or  in  close  relation  to, 
the  artery  may  be  observed  the  ter- 
minal part  of  the  anterior  division 
of  the  external  cutaneous  nerve. 

It  may  be  impossible  to  separate 
the  vente  comites  from  the  artery 
to  a  sufficient  extent  to  allow  the 
needle  to  pass.  In  such  case  the 
ligature  must  include  the  veins  as 
well  as  the  artery  (Fig.  26). 

Gorii'nient. — The  operation  is  ex- 
tremely easy.     Some  confusion  may 
arise  in  cases  where  the  superficiahs  volse  artery  has  a  high 
I  2 


Fig.  25, — LIGATURE  OP  THE  BA- 
DIAL  AND  ULNAR  AKTERIE3, 
AND  OF  THE  BRACHIAL  AT  THE 
BEND  OP  THE  ELBOW. 


11(3 


OPERATIVE    SUBGEltY. 


origiD,  and  lies  upon,  or  by  tlie  side  of,  tlie  radial.     This  is 
especially  the  case  when  the  branch  is  of  unusual  size. 

It  is   said    that  the  synovial   sheath  of  the 
A  ^  ^        flexor  carpi  radialis  tendon  has  been  accidentally 

opened  in  this  operation. 

2.  Ligature   in   the    Middle   Third  of  the 
"-        ,  Forearm. 

,     ^  Operation. — An  incision  two  inches  in  length 

is  made  in  the  hne  of  the  artery,  the  hmb  being 
in  the  position  indicated.  The  centre  of  the  in- 
cision corresponds  to  the  centre  of  the  forearm 
(Fig.  25).  In  cutting  through  the  subcutaneous 
tissues  care  must  be  taken  to  avoid  any  superficial 


m 


Fig.  26.— LIGA- 
TURE OF  THE 
RIGHT  RADIAL 
AT  THE  WRIST. 

A,    Fascia ;     a, 
Artery. 


vein  belonging  to  the  radial  or  median  veins. 


The  anterior  division  of  the  musculo-cutaneous 
nerve  lies  usually  in  the  hne  of  the  artery,  out- 
side the  deep  fascia  and  just  beneath  the  super- 
ficial veins. 
The  deep  fascia  is  laid  bare  and  is  divided  in  the  length  of 


the  original  wound. 


The  fibres  are  transverse  (Fig.  27). 


i.«  'i/' 


Fig.    27.— LIGATUHE  OF  THE  BIGHT   RADIAL,    ABOUT  THE  MIDDLE  THIRD  OF  THE 

FOBKARM. 


Superficial    Wound. — A,   Fascia ; 
B,  Sup,  long. 


Deep  Wound. — A,  Fascia  ;  B,  Sup.  long.  ; 
c,  Insertion  of  pron.  teres  ;  D,  Sup. 
brevis ;  a.  Artery  ;  1,  Radial  nerve. 


The  supinator  longus  muscle  is  now  exposed  about  the 
point  where  it  is  beginning  to  become  tendinous.     The  inner 


LIGATURE    OF  RADIAL    ARTERY.  117 

or  ulnar  border  of  the  muscle  is  defined  and  the  muscle  itself 
is  (Inixm  outwards.  The  elbow  may  bo  a  little  flexed  to  allow 
of  this  being  done  more  easily. 

The  vessel  is  now  found  lying  upon  the  insertion  of  the 
pronator  radii  teres,  with  which  it  is  connected  by  much  con- 
nective tissue.     The  nerve  may  or  may  not  be  seen  (Fig.  27). 

The  venae  comites  should  be  separated  as  well  as  is  possible 
and  the  needle  passed  from  wliichever  side  is  the  more  con- 
venient. 

Comment — As  the  supinator  longus  is  not  very  wide  at 
this  part  (especially  if  the  artery  be  sought  for  at  the  lower 
end  of  the  middle  third)  it  is  very  easy  to  expose  the  outer 
instead  of  the  inner  border  of  the  muscle,  in  which  case  the 
muscle  is  apt  to  be  drawn  inwards,  and  when  the  depths  of 
the  wound  are  opened  up  the  radial  nerve  is  reached.  This  is 
the  common  error  of  beginners. 

The  tendon  of  the  supinator  longus  as  a  rule  first  makes 
its  appearance  at  the  outer  border  of  the  muscle,  so  that 
if  this  tendinous  edge  be  exposed  the  operator  will  know  that 
he  has  laid  bare  the  wrong  side  of  the  muscle.  The  inner 
border  of  the  sujjinator  remains  muscular,  until  it  ends  some- 
what abru^Jtly  in  the  tendon. 

3.  Ligature  in  the  Upper  Third  of  the  Forearm. 
Operation. — This  operation  dift'ers  ver}^  little  from  the  last. 

The  incision  is  two  and  a  half  inches  in  length,  and  is  made  in 
the  line  of  the  artery.  The  centre  of  the  skin-cut  corresponds 
to  the  part  of  the  vessel  to  be  tied.  The  radial  or  other  sur- 
face vein  may  be  encountered  in  the  superficial  part  of  the 
wound.  After  the  deep  fascia  has  been  divided,  the  interval 
between  the  supinator  longus  and  pronator  teres  muscles  is 
opened  up.  There  is  no  difficulty  in  identifying  these  two 
structures :  the  fibres  of  the  supinator  are  vertical ;  those  of 
the  pronator  are  oblique.  In  muscular  subjects  the  supinator 
is  so  wide  that  its  inner  border  cannot  be  readily  exposed. 

Under  cover  of  the  supinator  the  radial  artery  Avill  be 
found.  The  nerve  is  not  in  relation  with  it.  The  needle 
should  be  passed  from  whichever  side  is  the  more  convenient. 

4.  Ligature  of  the  Radial  in  the  Tabatiere  Anatomique. 
— Anato'my. — The  tabatiere  anatomique  is  a  triangular  space 
bounded  on  one  side  by  the  extensor  ossis  metacarpi  poUicis 


118  OPERATIVE    SURGERY. 

and  extensor  primi  internodii,  and  on  the  other  side  by 
the  extensor  secundi  internodii  poUicis.  The  base  is  repre- 
sented by  the  lower  edge  of  the  posterior  annular  hgament. 
In  the  floor  of  the  space  are  the  trapezium,  with  a  part  of  the 
scaphoid  and  of  the  base  of  the  first  metacarpal  bone. 

The  radial  artery  runs  over  the  external  lateral  ligament  of 
the  wrist,  just  below  the  styloid  process,  passes  under  the  ex- 
tensors of  the  metacarpal  bone  and  first  phalanx  of  the  thumb, 
and  crosses  the  tabatiere.  Its  course  is  here  represented  by  a 
line  drawn  from  the  apex  of  the  styloid  process  of  the  radius 
to  the  posterior  angle  of  the  first  interosseous  space. 

The  cephahc  vein  of  the  thumb  crosses  the  space  pos- 
teriorly, as  does  also  the  internal  division  of  the  terminal 
branch  of  the  radial  nerve.  A  branch  of  the  anterior  division 
of  the  external  cutaneous  nerve  accompanies  the  artery  which 
gives  off,  while  in  the  upper  part  of  the  space,  the  posterior 
carpal  and  first  interosseous  branches. 

Operation. — This  procedure  belongs  rather  to  that  series 
of  dissecting-room  operations  which  are  of  value  as  demon- 
strating anatomical  loioAvledge. 

The  hand  is  placed  upon  its  ulnar  border,  and  is  firmly 
fixed  there  by  an  assistant,  who  at  the  same  time  holds  the 
thumb  extended  and  abducted  and  the  fingers  straight. 

An  incision,  about  one  inch  in  length,  is  made  along  the 
centre  of  the  tabatiere,  parallel  to  the  extensor  of  the  meta- 
carpal bone  of  the  thumb,  and  so  placed  as  to  commence  at 
the  level  of  the  radial  styloid  process  and  lie  midway  between 
the  extensor  ossis  and  the  extensor  of  the  second  phalanx  of 
the  thumb.  The  incision  will  cross  the  artery  a  little  obliquely. 
The  cephalic  vein  of  the  thumb  must  be  avoided.  The  artery 
is  hgatured  in  the  middle  of  its  course.  It  will  probably  be 
impossible  to  separate  the  venas  comites. 

It  is  said  that  in  performmg  this  operation  carelessly  the 
synovial  sheaths  of  the  adjacent  tendons  have  been  opened 
up,  or  the  joint  between  the  scaphoid  and  the  trapezium  has 
been  exposed. 

For  the  variations  in  the  radial  artery,  see  page  123. 

THE   ULNAR   ARTERY   (ill.). 

Anatomy. — This,  the  largest  artery  of  the  forearm,  follows 


LIGATURE    OF    ULNAR    ARTERY.  119 

a  curved  course  in  the  upj)er  third  of  the  Hmb.  It  is  perfectly 
straight  in  direction  in  the  lower  two-thirds. 

In  the  first  half  of  its  course  in  the  forearm  it  is  deeply- 
placed  beneath  the  superficial  flexors,  viz.,  the  pronator 
radii  teres,  flexor  carpi  radialis,  palmaris  longus,  and  flexor 
sublimis.  From  about  the  middle  of  the  forearm  to  a  point 
within  one  inch  of  the  wrist,  the  vessel  is  overlapped  by  the 
flexor  carpi  ulnaris.  For  the  last  inch  of  its  course  in  the 
forearm  it  is  superficial,  and  is  covered  only  by  the  integu- 
ments and  the  fascia. 

The  vessel  lies  at  first  upon  the  insertion  of  the  brachialis 
anticus,  and  then  for  the  rest  of  its  course  in  the  forearm 
upon  the  flexor  profundus. 

Yenai  comites,  united  by  many  cross  branches,  accompany 
the  vessel. 

The  ulnar  nerve  comes  in  contact  with  the  arter}^  at  a 
point  a  little  above  the  middle  of  the  forearm.  Throughout 
the  lower  half  of  the  forearm  the  two  are  close  together,  the 
nerve  lying  to  the  inner  side  of  the  artery. 

Line  of  the  Artery. — The  ulnar  in  the  lower  two-thirds  of 
its  course  in  the  forearm  is  represented  by  a  line  drawn  from 
the  tip  of  the  internal  condyle  of  the  humerus  to  the  radial 
side  of  the  pisiform  bone. 

The  curve  of  the  vessel  in  the  upper  third  of  its  course  is 
such  that  a  line  draAvn  from  the  commencement  of  the  artery 
— at  the  middle  of  the  bend  of  the  elbow — to  the  radial  side 
of  the  pisiform  bone,  will  scarcely  touch  the  vessel  in  any 
part  of  its  course. 

The  upper  third  of  the  artery  is  too  deeply  placed  to  be 
exposed  for  ligature,  unless  it  be  actually  laid  bare  in  a 
wound. 

Indications.— These  have  been  already  alluded  to  (page 
115).  The  arter}^  is  secured  only  in  the  lower  two-thirds  of  the 
limb. 

Position. — As  for  ligature  of  the  radial  artery  in  the  fore- 
arm. 

1.  Ligature  in  the  Lower  Third  of  the  Forearm. 

Operation. — An  incision,  two  inches  in  length,  is  made 
along  the  line  of  the  artery,  just  to  the  radial  side  of  the  flexor 
car|)i  ulnaris  tendon.     The  incision  terminates  an  inch  or  less 


120  OPERATIVE    SUBGEBY. 

above  the  pisiform  bone  (Fig.  25).  Care  must  be  taken  to 
avoid  any  tributary  to  the  superficial  ukiar  vein  which  may 
be  over  the  Ime  of  the  artery.  The  deep  fascia — which  is 
here  very  slender — is  exposed  and  divided. 

The  tendon  of  the  flexor  carpi  ulnaris  muscle  is  now  dis- 
played.    The  wi-ist  is  a  little  flexed  to  relax  the  tendon,  which 
is  gently  drawn  inwards  by  a  blunt  hook.     The  vessels  are 
now  exposed.     The  artery  in  this  situation  is  bound  down  to 
the  flexor  profundus  by  a  definite  layer  of  fascia.     This  must 
be  carefully  divided.     The  nerve  is  close  to  the  artery,  and 
upon  its  inner  side  (Fig.  28).     It  may  be  impossible  to  isolate 
the  artery  from  the  companion  veins.     The 
needle    is    passed    from    within   outwards. 
/;x     ,,-''^      The  palmar  cutaneous  branch  of  the  ulnar 
nerve  hes  upon  the  artery  in  this  situation, 
—  1     and  must  be  avoided. 

Comment. — It  is  possible  that  the  opera- 

;"'---  B     tor  may  expose  the  inner  side  of  the  flexor 

^  carpi  ulnaris  tendon  by  mistake.     On  this 

(the  wrong)  side  of  the  tendon,  muscular 

fibres  will  be  found   entering   the   tendon 

"the"e'ight  ulnar  at     almost  down  to  the  wrist.     On  the  radial 

THE  WRIST.    ^  g-^g  |.|^g  tendon  is  quite  clear.     Care  must 

**'flex!^carp.  uin.Ten-     be  taken  uot  to  wound   the  synovial  sac, 

don;  a.  Artery;  1,     ^j^ich    accompanies    the    flexor    sublimis 

Ulnar  nerve.  -C^ 

diffitorum  tendons  beneath  the  annular 
Ugament.  Normally  the  ulnar  gives  off  no  branch  in  this 
situation.  The  posterior  carpal  arises  a  httle  above  the  pisi- 
form bone. 

2.  Ligature  in  the  Middle  Third  of  the  Forearm. 

Operation. — An  incision,  from  two  and  a  half  to  three 
inches  in  length,  according  to  the  muscular  condition  of  the 
hmb,  is  made  precisely  in  the  line  of  the  artery  (Fig.  25). 
Beneath  the  integuments  the  anterior  ulnar  vein  and  branches 
of  the  anterior  division  of  the  internal  cutaneous  nerve  are  apt 
to  be  encountered.  The  deep  fascia  is  thin,  and  is  divided  in 
a  hne  parallel  with,  but  a  little  to  the  outer  side  of  the  line  of, 
the  skin  incision. 

The  surgeon  now  seeks  for  the  gap  between  the  flexor 
carpi  ulnaris  muscle  and  the  flexor  sublimis  digitorum  (Fig. 


LIGATURE    OF    ULNAR    ARTERY. 


121 


29).  The  position  of  this  interval  is  sometimes  indicated  by  a 
white  hue.  (See  Comment  upon  the  opera- 
tion.) The  gap  is,  however,  best  demon- 
strated by  the  touch,  the  left  forefinger  being 
used  for  the  purpose.  As  soon  as  the  inter- 
muscular space  has  been  made  evident,  the 
wrist  is  a  little  flexed  to  relax  the  muscles. 
The  flexor  carpi  ulnaris  is  now  drawn  inwards 
by  means  of  a  broad-bladed  retractor.  The 
flexor  sublimis  is  in  hke  manner  drawn  a 
little  outAvards.  The  surgeon  opens  up  the 
vertical  intermuscular  space  thus  demon- 
strated, and  at  the  bottom  of  it  will  prob- 
ably first  be  found  the  ulnar  nerve.  To 
the  outer  side  of  the  nerve  is  the  artery 
(Fig.  30).  The  fascia  binding  down  the 
vessels  in  this  situation  is  slender.  There  is 
usually  no  difficulty  in  separating  the  artery 
from  its  venae  comites. 

The  needle  should  be  passed  from  within 
outwards  so  as  to  avoid  the  nerve. 

Comment. — This  operation  is  associated 

with  considerable  difficulty  if  care- 
lessly performed,  and  the  i3rocedure 
is  surrounded  by  many  possibihties 
of  error. 

The  chief  difficulty  is  to  demon- 
strate the  gap  betAveen  the  flexor  carpi 
ulnaris  and  flexor  sublimis  muscles. 

The  "  white  line  "  which  is  said  to 
mark  this  gap  is  not  to  be  relied 
upon.  There  may  be  no  trace  of 
such  a  line :  it  may  be  very  faintly 
indicated,  or  the  position  of  the  in- 
terspace may  be  marked  by  a  yelloAV 
„     „.  fatty  Kne.     The   white   hne  is   best 

Fig.     30. — LIGATUKE    OP      EIGHT  "^  ,  1  i    • 

ULNAR  AT  THE  MIDDLE  THIRD    seeu  m  youug  muscular  subjects.     In 

OF   THE   FOREARM.  .i  j  n  .       1    •-     •  11  i 

Deep  Wound.-A,  Fascia ;  B.  Flex.      ^'^^  ^^^d  and  WaStcd  lt_  IS  USUaUy  ab- 

subiimis ;  c.  Flex.  carp,  ui-    scut.    In  corpulcut  subiccts  the  linear 

naris ;  D,  Flex,  profundus;  a,       -,  •,/•/••  i 

Artery ;  1,  Ulnar  nerve.  depOSlt  Of  fat  IS  COmmonly  present. 


Fig.  29.  —  LIGATURE 
OF  THE  RIGHT 
ULNAE  AT  THE 
MIDDLE  THIRD  OF 
THE    FOREARM. 

Sujiei-ficial  Wound. — 

A,    Fascia ;     B,    Pal- 

maris    longus ;     C, 

Flex.  carp,  ulnaris ; 

6,  Superficial  vein. 


122 


OPERATIVE    SURGERY. 


The  white  Une,  when  it  does  exist,  indicates  the  tendinous 
margin  of  the  flexor  carpi  uhiaris.  This  tendinous  tissue 
belongs  to  the  tendon  of  origin  of  the  muscle,  and  not  to  that 
of  the  insertion,  as  usually  stated.  At  the  level  of  the  centre 
of  the  forearm  there  is  seldom  any  trace  of  the  tendon  of 
insertion.  A  faint  variety  of  the  white  hne  is  sometimes 
produced  by  an  unusual  intermuscular  septum.  The  flexor 
carpi  ulnaris  is  much  more  closely  adherent  to  this  septum 
than  is  the  flexor  subhmis,  and  when  the  fascia  is  divided  the 
septum  adheres  to  the  former  muscle,  thus  producing  a 
species  of  fascial  margin. 

The  interspace  between  the  two  muscles  in  question  is 
not  quite  straight,  i.e.,  is  not  quite  vertical  when  the  limb  is 
in  position  for  the  operation.  The  flexor  carpi  ulnaris  over- 
laps the  flexor  subhmis  a  little,  and  the  hne  of  the  interspace 
is  directed  as  is  shown  at  a  in  Fig.  31.  The  fibres  of  both 
the  muscles  follow  the  long  axis  of  the  hmb. 

If  the  division  of 
.3  i^*-        I  n  the    deep    fascia     be 

exactly  in  the  line  of 
the  skin  incision,  i.e., 
in  the  hne  of  the 
artery  x,  the  knife 
will  probably  cut  u]  )on 
the  flexor  carpi  ul- 
naris. 

By    dividing    the 

fascia  a  httle  more  to 

THE  FORKAiiM  tho  outer  side  as  ad- 


-TKANSVERSK    SECTION 


(diagrammatic),  to    show  the    iNTERMustuLui   yjcad   thc  kuifc  COUieS 

a  Ulnar  ^^^^  the  flcxor  sul)li- 
avoidod ; 
X,  the  sui-f^ical  line  of  the  ulnar  artery  ;  1,  "Ulnar 


vessels;  2,  Radial  vessels  ;  3,  Median  nerve. 


SPACES    ABOUT    THE    MIDDLE    THIRD. 

nitials  indicate  the  tendons  and  muscles, 
artery  interspace  ;  i,  Interspace  to  be  avoided;   mis  (see  Fig.  31),   and 

by  working  inwards 
the  oblique  gap  be- 
tween the  muscles  is  made  out.  This  gap  is  always  best  de- 
monstrated by  the  finger.  It  is  often  indicated  by  one  or 
more  cutaneous  arteries  Avhich  escape  here  and  form  an  excel- 
lent guide  to  the  main  artery.  The  interspace  should  be  sought 
for  at  the  lower  part  of  the  wound,  and  the  separation  of  tlie 
two  nuiscles  should  take  place  from  below  upwards. 


LIGATURE    OF   BBAGHIAL    ARTERY.  123 

It  may  be  noted  that  the  flexor  sublimis  at  the  middle 
third  of  the  forearm  presents  a  few  fine  commencing  tendon 
fibres. 

In  muscular  subjects  care  should  be  taken  that  the 
incision  is  made  long  enough. 

It  is  only  by  the  display  of  great  carelessness  that  it  would 
be  possible  to  open  up  the  interspace  between  the  flexor  sub- 
limis and  palmaris  longiis  muscles. 

When  the  proper  interval  has  been  found  between  the 
flexor  sublimis  and  the  flexor  carpi  ulnaris,  it  is  not  un- 
common for  the  beginner — impressed  with  erroneous  vieAvs  as 
to  the  depths  of  the  artery — to  proceed  too  deeply  and  too  far 
to  the  inner  side,  and  to  actually  pass  by  the  ulnar  nerve  and 
open  up  the  interspace  between  the  flexor  carpi  ulnaris  and 
the  flexor  profundus  digitorum.     (See  h,  Fig.  31.) 

This  may  readily  happen  if  the  former  muscle  be  dragged 
too  much  to  the  inner  side. 

Collateral  Circulation  after  Ligature  of  the  Radial  or 
Ulnar  Artery. — After  ligature  of  one  of  these  vessels,  the 
collateral  circulation  is  very  readily  and  freely  established, 
through  the  cross  anastomoses  between  the  arteries  in  question, 
through  the  palmar  and  carpal  arches  and  through  the  inter- 
osseous vessels. 

Varieties  of  the  Radial  and  Ulnar  Arteries. 

1.  The  radial  has  been  found  outside  the  fascia,  and 

subcutaneous. 

2.  The  ulnar  may  be  subcutaneous  or  subfascial  in  its 

entire  course. 

3.  The   median  artery   may   be  of  large  size  and  be 

largely  concerned  in  the  suj)ply  of  the  palm. 

4.  The  radial  artery  may  be  absent. 

THE   BRACHIAL   ARTERY   (ll.). 

Anatomy. — The  brachial  artery  commences  at  the  lower 
margin  of  the  teres  major,  and  bifurcates  at  a  point  on  a  level 
with  the  neck  of  the  radius.  It  lies  m  the  depression  along 
the  inner  borders  of  the  c  raco-brachialis  and  biceps  muscles. 

In  the  upper  two-thirds  of  its  course  it  lies  on  the  inner 
aspect  of  the  shaft  of  the  humerus,  and  can  be  compressed 


124  OPERATIVE    8UBGEUY. 

against  the  bone  by  pressure  in  a  direction  outwards  and 
slightly  backwards.  In  its  lower  third  the  humerus  is 
behind  it,  and  compression,  to  be  effectual,  should  be  directed 
backwards.  It  runs  between  the  skin  and  deep  fascia  as  far 
as  the  elbow,  where  it  dips  into  the  interval  between  the 
supinator  longus  and  pronator  teres  muscles,  and  passes 
beneath  the  bicipital  fascia.  In  muscular  subjects  the  artery 
may  be  overlapped  to  a  considerable  extent  by  the  edge  of 
the  biceps. 

It  hes,  in  order  from  above  downwards,  upon  the  long 
head  of  the  triceps  (the  musculo-spiral  nerve  and  superior 
profunda  artery  intervening),  the  inner  head  of  the  triceps,  the 
insertion  of  the  coraco-brachialis  (at  the  middle  of  the  arm), 
and  the  brachialis  anticus.  It  is  fixed  to  the  latter  muscle 
by  its  sheath.  It  is  accompanied  by  venas  comites,  one  on 
each  side,  which  are  connected  with  one  another  by  many 
transverse  branches.  The  inner  of  these  veins  is  much  the 
larger.  The  basilic  vein  lies  to  the  inner  side  of  the  artery, 
but  is  separated  from  that  vessel,  in  the  lower  part  of  the  limb, 
by  the  fascia.  It  pierces  the  fascia  about  the  middle  of  the 
arm.  It  may  then  attend  the  artery  to  the  axilla,  or  may  join 
at  once  -with  the  inner  of  the  two  venaj  comites. 

The  median  nerve  crosses  in  front  of  the  artery  about  or 
below  its  middle,  lying  to  the  outer  side  of  the  vessel  above 
that  point,  and  to  its  inner  side  below. 

The  ulnar  nerve  is  to  the  inner  side  of  the  artery  as  far  as 
the  insertion  of  the  coraco-brachialis ;  it  then  leaves  the  vessel 
to  run  to  the  gap  between  the  internal  condyle  and  the 
olecranon. 

The  internal  cutaneous  nerve  lies  in  front  or  to  the  inner 
side  of  the  artery,  in  about  the  upper  half  of  its  course.  The 
nerve  pierces  the  fascia,  and  becomes  subcutaneous  about  the 
middle  of  the  arm. 

The  inferior  profunda  artery  is  represented  by  a  line  drawn 
from  the  inner  side  of  the  humerus  at  its  middle  to  the  back 
part  of  the  internal  condyle.  The  nutrient  artery  enters  the 
bone  at  its  inner  aspect  oi)posite  the  deltoid  insertion,  and  the 
anastomotic  vessel  comes  off  aljout  two  inches  above  the  bend 
of  the  elbow. 

At  the  bend  of  the  elbow  the  biceps  tendon  can  be  AveU 


LIGATURE    OF   BRACHIAL   ARTERY.  125 

felt,  its  outer  ed<(c  being  more  evident  than  the  inner.  The 
crease  in  the  skin  called  the  "fold  of  the  elbow"  is  placed  some 
little  way  above  the  line  of  the  articulation.  At  the  spot 
where  the  biceps  tendon  ceases  to  be  distinctly  felt,  and  at  the 
outer  side  of  that  tendon,  the  median,  median  basilic,  median 
cephahc  and  deep  median  veins  join.  The  median  basilic  vein 
passes  in  front  of  the  biceps  tendon,  the  brachial  artery,  and 
the  median  nerve.  The  median  basilic  vein  may  cross  the 
artery  abruptly  and  be  comparatively  free  of  it  except  at  the 
point  of  crossing,  or  it  may  run  for  some  distance  quite  in 
front  of  the  artery,  or  crossing  it  early,  it  may  lie  parallel  Avith 
the  vessel,  although  at  a  different  level  for  the  gi-eater  part  of 
its  course. 

Line  of  the  Artery. — When  the  arm  is  extended  and 
abducted  with  the  hand  supine,  the  brachial  artery  corre- 
sponds to  a  line  drawn  from  the  outlet  of  the  axilla  (at  the 
junction  of  its  middle  and  anterior  thirds)  to  the  middle  of 
the  bend  of  the  elbow. 

Indications. — The  artery  is  rarely  ligatured  at  the  bend  of 
the  elbow  except  for  wounds  and  for  traumatic  arterio-venous 
aneurysm.  In  the  arm  it  is  often  secured  for  wound,  for 
hsemorrhage  from  the  palmar  arches  and  from  the  elbow  and 
forearm,  and  for  traumatic  aneurysm.  Spontaneous  aneurysm 
is  very  rare  in  the  brachial  artery.  Dr.  Holt  {Amer.  Joarn. 
Med.  Sciences,  April,  18cS2)  only  succeeded  in  collecting  thir- 
teen cases  of  such  aneurysm. 

Position. — In  securing  the  artery  at  the  bend  of  the  elbow, 
the  hmb,  extended  and  abducted,  ma}-  be  allowed  to  rest  upon 
the  olecranon.     It  should  not  be  over-extended. 

In  dealing  with  the  vessel  in  the  ai-m,  the  hmb  should  be 
extended  and  abducted,  with  the  hand  supine,  and  should  be 
held  away  from  the  body.  The  arm  itself  should  not  be  sup- 
ported in  any  way,  but  the  limb  should  be  held  by  the  forearm 
by  an  assistant. 

The  surgeon  may  make  the  incision  from  above  doA\Ti wards 
on  both  sides  of  the  body,  standing  to  the  outer  side  of  the 
limb  on  the  right  side,  and  between  the  trunk  and  the  limb 
on  the  left  side.  Or  on  the  left  side  the  operator  may  place 
himself  to  the  outer  side  of  the  hmb,  and,  bending  over  it, 
may  make  the  incision  from  below  upwards. 


126 


UFEitATIVE    SURGE UY. 


1.  Ligature  at  the  Bend  of  the  Elbow. 

Operation. — The  arm  having  been  placed  in  the  position 
indicated,  the  surgeon,  by  flexing  and  extending  the  limb, 
makes  out  the  exact  position  of  the  biceps  tendon,  and  by 
compressing  the  veins  of  the  upper  arm,  renders  evident  the 
median  basihc  vein. 

An  incision,  two  inches  in  length,  is  made  through  the 
skin,  along  the  inner  edge  of  the  biceps,  and  parallel  with 
its  margin.  The  wound  will  therefore  be  oblique,  and  it 
should  be  so  placed  that  its  centre  corresponds  to  the  mark 
on  the  skin  called  the  "fold  of  the  elbow"  (Fig.  25).  The 
upper  end  of  the  ixicision  mil  correspond  to  the  level  of  the 
tip  of  the  internal  condyle.  If  the  veins  be  normally  dis- 
posed, the  skin  wound  will  he  to  the  outer  side  of  the  median 
basihc  vein,  and  nearly  parallel  to  it. 

As  soon  as  the  vein  is  exposed,  it  should  be  drawn  inwards. 
The  bicipital  fascia  is  now  demonstrated,  and  divided  in  the 
line  of  the  original  incision.  Its  fibres  are  directed  obhquely 
downwards  and  inwards.  The  artery,  with  its  venae  comites, 
will  now  be  exposed.  The  vessel  ^vilL  here  be  found  to  be 
very  movable  and  free  from  connective  tissue  attachments, 
although  sometimes  surrounded  by  much  fat  (Fig.  32). 

The  venge  comites  having  been 
separated,  the  needle  is  passed  from 
within  outwards.  The  median  nerve 
does  not  come  conspicuously  into  the 
field  of  the  operation.  It  is  nearest  to 
the  artery  (on  its  inner  side)  at  the 
upper  part  of  the  wound. 

Comraent. — Care  should  be  taken 
that  the  operation  is  performed  so  as 
to  ensure  primary  healing.  Suppura- 
tion follomng  this  procedure  has  led 
to  a  stiff  elbow.  The  median  basilic 
vein  is  closely  attached  to  the  thin 
integument,  and,  unless  made  quite 
evident,  may  easily  be  wounded. 

2.  Ligature  at  the  Middle  of  the 
Arm. 

Operation 


^m?^ 


'^i 


Fig.  32.— LIGATORE  OF  THE 
RIGHT  BKACHIAL  AT  THK 
BEND  OF  THE  ELBOW. 

A,  Fascia  ;  B,  Bicepa  tendon  ; 
0,  Bicipital  fascia;  a,  Artery; 
6,  Vense  comites  ;  c,  BasUic 
vein  ;  1,  Median  nerve. 


The  hmb  having  been 


LIGATURE    OF   BRACHIAL    AUTKRY. 


1-n 


—A 


-  C 


placed  in  the  position  indicated,  an  incision  about  two  and  a 
half  inches  in  length  is  made  along  the  inner  edge  of  the 
biceps  muscle,  in  the  line  of  the  artery  (Fig.  34). 

The  fascia,  which  is  here  thin,  is  exposed  and  divided,  and 
the  muscular  layer  is  reached.  It  is  extremely  important  that 
the  inner  margin  of  the  biceps  be  clearly  exposed  and  surely 
identitied.  The  muscle  is  displaced  a  httle  outwards,  and  the 
pulsation  of  the  vessel  is  sought  for.  A  little  dissection 
exposes  the  median  nerve — if  it  be  not  already-  in  view  (Fig. 
33).  In  the  middle  of  the  arm  the  nerve  usually  lies  in  front 
of  the  artery.  In  applying  a  Hgature  to 
any  part  of  the  brachial,  at  or  above 
the  middle  of  its  course,  the  nerve  should 
be  drawn  outwards.  If  the  brachial  be 
exposed  below  the  middle  section,  the 
nerve  is  more  conveniently  displaced  in- 
wards. 

While  the  artery  is  being  exposed  the 
elbow  may  be  flexed  for  a  moment. 

The  sheath  of  the  artery  having 
been  opened,  and  the  venae  comites 
separated  as  well  as  possible,  the 
needle  is  passed  from  the  nerve.  The 
inner  of  the  two  companion  veins  is 
usually  much  the  larger.  '■^._.'- 

In  the  upper  part  of  its  course  the  ^ig-  33.— ligature  of  the 

.  r.       I  1  1    •     T  RIGHT    BRACHIAL    AT  THE 

mner   margin   or  the     coraco-brachiahs      middle  of  the  arm. 

muscle  is  exposed  in  the  place  of  the  a,  Fascia;  b,  Biceps;  c, 
1  •  -I     A  1  •      1    •  ,  Triceps;    a.    Artery;    b, 

biceps,  and  the  ulnar  nerve  is  lymg  to  vena  comes ;  i,  Median 
the  inner  side  of  the  vessel.  ^^^;7^  'ne^vj."*""'"''^  ''''*^" 

Goiniinent. — This    artery    is    by    no 
means  so  easy  to  ligature  as  may  appear ;  and  in  an  operative 
surgery  class  no  more  glaring  mistakes  are  made  than  occur 
in  the  course  of  searching  for  this  superficial  vessel. 

In  the  first  place,  the  arm  should  be  unsupported,  and  be 
at  right  angles  to  the  trunk.  If  the  arm  be  allowed  to  rest 
upon  a  table,  the  triceps  may  be  pushed  forwards,  and  may 
be  then  mistaken  for  the  biceps ;  while  the  ulnar  nerve  has 
been  mistaken  for  the  median.  This  observation  especially 
apphes  to  the  middle  third  of  the  hmb. 


128  OPERATIVE    SURGERY. 

The  vessel  is  mobile,  and  is  easUy  displaced,  and  in  dra^ving 
the  biceps  aside  roughly  with  a  retractor,  the  vessels  and  the 
median  nerve  have  been  withdraA\^i  from  the  field  of  the  opera- 
tion, and  possibly  the  ulnar  nerve  brought  into  view.  The  clear 
identification  of  the  biceps  margin  is  essential  The  advice 
sometimes  given,  that  the  "  sheath  of  the  muscle  "  should  not 
be  opened,  is  neither  sound  nor  very  precise. 

The  pulse  in  the  brachial  is  often  much  feebler  than  would 
be  imagined :  and  this  is  especially  the  case  in  dealing  with 
severe  hsemori'hage.  The  pulsation  may  be  so  clearly  trans- 
mitted to  the  median  that  that  nerve  has  been  mistaken  for 
the  artery. 

It  is  asserted  that  the  basilic  vein  has  been  mistaken  for 
the  arterv.  Tillaux  states  that  a  large  inferior  profunda  artery 
has  been  taken  for  the  brachial. 

If  the  incision  be  made  too  much  to  the  inner  side  of  the 
proper  line,  the  basUic  vein  may  be  wounded,  especially  when 
it  is  superficial,  i.e.,  in  the  lower  segment  of  the  arm. 

In  very  muscular  subjects  the  biceps  may  overlap  the 
artery  considerably.  The  frequent  abnormalities  of  the  brachial 
must  in  all  instances  be  borne  in  mind. 

Collateral  Circulation  after  Ligature  of  the  Brachial 

Artery. 

1.  If  above  the  origin  of  the  superior  profunda. 

Above.  Below. 

Posterior  circumflex     with     Ascending  branches  of  superior  profunda. 

2.  If  below  the  origin  of  the  inferior  profunda. 

Above.  Below. 

(  Anastomotic. 

Superior  profunda  with  <  Radial  recurrent, 

V  Posterior  interosseous  recurrent. 

f  Anastomotic. 

Inferior  profunda  with  <  Posterior  ulnar  recurrent. 

(  Posterior  interosseous  recurrent. 

Varieties  of  the  Brachial  Artery. 

1.  The  artery  may  run  towards  the  inner  condyle,  and 

pass  beneath  a  supra-condyloid  process. 

2.  The  artery  may  show  a  high  division.     The  branch 

prematurely  separated  will  be,  in  order  of  frequency, 


LIGATURE    OF   AXILLARY    ARTERY.  129 

the  radial,  the  ulnar,    the   interosseous,  or  a  vas 
aberrans. 

The  site  of  the  high  division  is  most  usually  in  the  upper  third  of  the  arm, 
less  often  in  the  lower  third,  and  rarest  in  the  middle  third. 

The  two  vessels  usually  run  side  by  side,  the  abnormal  artery  being  the 
more  superficial. 

3.  The  median  nerve  may  pass   behmd   the   brachials 

arter}'. 

4.  The  vessel  may  be  crossed  by  a  muscular  sHp  derived 

from  the  pectorahs  major,  biceps,  coraco-brachialis, 
or  brachialis  anticus. 

THE   AXILLARY  ARTERY. 

Anatomy. — The  axillary  artery  extends  from  the  lower 
edge  of  the  first  rib  to  the  lower  margin  of  the  teres  major 
muscle. 

Its  position  is  much  influenced  by  the  position  of  the  arm. 
The  vessel  is  conveniently  divided  into  the  three  parts — the 
segment  above  the  pectorahs  minor,  the  segment  beneath  the 
muscle,  and  the  segment  beyond  the  muscle.  The  first  part 
measures  about  one  inch  in  length,  the  second  one  inch 
and  a  quarter,  and  the  third  part  about  three  inches. 

The  first  ijart  of  the  artery  is  deeply  placed,  is  covered 
in  by  the  pectorahs  major  and  costo-coracoid  membrane,  and 
is  invested  by  a  fairly  substantial  sheath.  It  is  overshadowed 
by  the  clavicle  and  the  subclavius  muscle.  It  rests  upon  the 
first  intercostal  space,  the  second  rib,  the  second  and  third 
serrations  of  the  serratus  magnus  muscle,  and  the  nerve  of 
Bell.  Crossing  over  the  front  of  the  vessel  from  without  in- 
wards ^re  the  cephahc  vein,  the  acromio-thoracic  vein,  and  the 
external  anterior  thoracic  nerve. 

The  cords  of  the  brachial  plexus  he  to  the  outer  side 
of  the  vessel. 

The  axillary  vein  is  of  large  size,  is  influenced,  as  to  its 
dimensions,  by  respiratory  movements,  is  superficial  to  the 
artery,  and  is  placed  on  its  inner  side.  When  the  arm  hes 
by  the  side  the  vein  is  actually  to  the  inner  side  of  the  artery : 
but  when  the  hmb  is  held  at  right  angles  to  the  body  the 
vein  is  drawn  across  the  artery,  and,  in  the  Uviug  subject, 
conceals  it. 
J 


130  OPEEATIVE    SVBGEBY. 

The  vein  is  somewhat  closely  attached  to  the  costo-coracoid 
membrane. 

The  acromio-thoracic  and  superior  thoracic  arteries  are 
given  off  from  this  part  of  the  vessel.  The  upper  border  of 
the  pectoralis  minor  is  represented  by  a  line  drawn  from  the 
third  rib,  near  its  cartilage,  to  the  coracoid  23rocess.  The 
lower  border  of  the  muscle  follows  a  line  dra^vn  from  a  cor- 
responding part  of  the  fifth  rib  to  the  same  process. 

The  second  part  of  the  artery  requires  no  notice. 

The  third  part  is  covered  by  the  pectoralis  major  at  first, 
and  then  only  by  the  integuments  and  fascia.  It  rests  upon 
the  sub-scapularis  and  the  tendons  of  the  latissimus  dorsi  and 
teres  major.  The  circumflex  and  musculo-spiral  nerves  pass 
behind  it.  The  coraco-brachialis  muscle  Hes  to  its  outer  side, 
and  the  axillary  vein  to  its  inner  side.  This  vein  is  formed 
by  the  junction  of  the  two  vense  comites.  This  junction  is 
usually  not  effected  until  the  lower  border  of  the  subscapularis 
muscle  is  reached  Thus  two  veins  are  commonly  found  in 
relation  with  the  lowest  part  of  the. artery,  and  if  the  basilic 
vein  has  not  yet  joined  the  inner  vena  comes,  three  veins 
may  be  met  with.  The  subclavian  vein,  in  the  form  of  a 
single  trunk,  may  not  have  an  existence  until  the  region  of 
the  clavicle  is  reached. 

The  ulnar  nerve  hes  to  the  inner  side  of  the  artery, 
between  it  and  the  vein.  The  nerve  of  Wrisberg  is  placed 
to  the  inner  side  of  the  vein.  The  internal  cutaneous  nerve 
and  the  inner  head  of  the  median  are  in  front  of  the  artery, 
while  the  trunk  of  the  median  and  the  musculo-cutaneous 
lie  to  the  outer  side. 

The  internal  cutaneous  and  the  median  are  the  ;nerves 
most  closely  connected  with  the  artery. 

The  subscapular,  posterior  and  anterior  circumflex  arteries 
come  off  from  the  third  part. 

Line  of  the  Artery. — A  line  from  about  the  centre  of  the 
clavicle  to  the  humerus,  close  to  the  inner  border  of  the 
coraco-brachiahs,  will  represent  the  artery  when  the  arm  is 
so  abducted  as  to  be  at  right  angles  to  the  body. 

Indications. — The  ligature  of  the  axillary  artery  is  prac- 
tically limited  to  its  third  part.  The  artery  has  been  tied 
for  wound,  for  haemorrhage  from  the  limb  below,  for  axillary 


LIGATURE    OF   AXILLARY  ARTERY. 


131 


and  brachial  aneurysm,  and  for  the  treatment  of  subclavian 
aneurysm,  by  the  distal  operation. 

The  axillary  appears  to  have  been  tirst  tied  by  R.  Chamber- 
laine,  of  Jamaica,  for  traumatic  aneurysm  of  the  axilla  in  1815 
(Med.-Chir.  Trans.,  vol.  vi.,  page  128).  The  tirst  part  of  the 
vessel  was  secured,  and  the  operation  was  successful      Dr 


Fig.  34. 


-LIGATURE  OF  THE  BRACHIAL  ABOUT  THE  MIDDLE  OF  THE  ARM,  AND  OF 
THE  THIRD  PART  OF  THE  AXILLARY. 


Holt  (Amer.  Journ.  Med.  Sciences,  1882)  reports  a  ligature  oi 
the  lirst  segment  of  the  artery  for  the  relief  of  haemorrhage 
attending  a  ligature  of  the  third  part.  The  patient  did  well. 
In  exceedingly  few  instances,  however,  has  the  first  segment 
of  the  vessel  been  secured ;  and  in  very  few  have  the  results 
been  encouraging. 

The  conditions  requiring  the  obhteration  of  the  first  part 
of  the  artery  must  be  so  remarkably  uncommon  that  the 
operation  can  scarcely  rank  as  a  regular  surgical  procedure. 
When  a  high  ligature  is  required,  it  should  be  applied  to 
the  third  part  of  the  subclavian. 

The  dangers  and  difiiculties  attending  a  high  hgature  of 
the  axillary  are  so  considerable  as  to  render  the  procedure 
questionable.  The  wound  is  deep,  the  vein  is  closely  con- 
nected with  the  costo-coracoid  membrane,  is  very  prominent 
and  large,  and  apt  to  be  torn.  The  danger  from  the  entrance 
of  air  into  a  vein  is  not  inconsiderable,  and  the  operation 
involves  the  opening  up  of  a  deep  and  extensive  area  of  con- 
nective tissue. 

1.  Ligature  of  the  Third  Part. 

Operation. — The  patient  is  placed  upon  the  back,  close  to 


J  -1 


132 


OPERATIVE    SURGERY. 


the  edee  of  the  table,  and  has  the  shoulders  raised.     The 
arm  is  at  right  angles  to  the  body,  and  is  held  horizontah}'-. 

The  surgeon  may  place  himself  between  the  arm  and  the 
thorax  when  about  to  secure  either  artery.  It  is  the  practice 
of  some  to  stand  to  the  outer  side  of  the  hmb,  near  the 
patient's  head,  and  to  bend  over  the  extremity,  when  operating 
upon  the  right  axillary.     The  axilla  should  be  shaved. 

An  incision,  about  three  inches  in  length,  is  made  along 
the  hne  of  the  artery.  It  com- 
mences at  the  middle  of  the  outlet 
of  the  axilla,  at  the  junction  of  its 
anterior  and  middle  thirds,  and  is 
continued  down  along  the  inner 
margin  of  the  coraco-brachiahs 
muscle  (Fig.  34).  The  knife  should 
be  held  -with  the  blade  horizontal. 
After  the  integuments  and  fascia 
have  been  divided,  the  inner  mar- 
gin of  the  coraco-brachiahs  should 
be  thoroughly  exposed.  This 
muscle,  mth  the  musculo-cutaneous 
nerve,  is  then  drawn  gently  out- 
wards. The  position  of  the  artery 
may  now  be  determined  with  the 
finger.  In  exposing  it  the  median 
nerve  is  at  once  made  evident,  and 
should  be  dra^vn  outwards  by 
means  of  a  smaU.  blunt  hook.  The 
internal  cutaneous  nerve  should 
be  gently  displaced  inwards.  The  venas  comites  need  to  be 
well  demonstrated.  The  artery  having  been  cleared,  the 
needle  is  passed  from  -within  outwards  (Fig.  35). 

Comment. — The  numerous  nerves  in  relation  wdth  this 
part  of  the  vessel  somewhat  confuse  the  operation.  The 
veins  are  apt  to  obscure  the  vessel  There  may  be  three 
veins  in  relation  to  this  part  of  the  axillary — the  tAvo  vena3 
comites  and  the  still  free  basihc.  Abnormalities  in  the  artery 
must  be  anticipated.  A  muscular  slip  passing  from  the  latissi- 
mus  dorsi  to  join  the  pectoralis  major,  biceps,  or  coraco- 
brachiahs,   may  cross   over   the   vessels.      Such   a   slip  may 


Fig.  35. — LIGATURE  OF  THE  BIGHT 
AXILLARY  ARTERY  (.3rD   PART). 

A,  Fascia  ;  B,  Coraco-brachialis  ; 
a,  Artery  ;  h,  Veuse  comites  ;  1, 
Median  nerve  ;  2,  Int.  cutaneous 
nerve. 


LIGATURE    OF   AXILLARY    ARTERY.  133 

readily  be  mistaken,  when  large,  for  the  coraco-bracliialis 
muscle. 

The  ligature  should  not  be  applied  too  near  any  one  of  the 
branches  of  the  artery. 

2.  Ligature  of  the  First  Part. 

0 J  aeration. — The  patient  lies  upon  the  back,  close  to  the 
margin  of  the  table,  with  the  upper  part  of  the  body  raised. 
The  point  of  the  shoulder  should  be  carried  well  back,  and  to 
effect  this  a  hard  cushion  may  be  placed  between  the  scapuLe. 
The  arm  is  allowed  to  lie  by  the  patient's  side.  It  must  not 
be  dragged  upon  so  as  to  depress  the  point  of  the  shoulder. 

The  operator  should  stand  upon  the  outer  side  of  the  limb, 
near  the  patient's  trunk,  when  dealing  with  the  left  side,  and 
near  the  head  when  deahng  with  the  right.  A  good  reflected 
light  is  necessary. 

A  slightly  curved  incision,  with  the  convexity  doAvnwards, 
is  made  across  the  supra-clavicular  fossa.  The  cut  commences 
just  outside  the  sterno-clavicular  joint,  and  ends  just  outside 
the  coracoid  process.  It  passes  about  half  an  inch  below  the 
clavicle,  and  the  centre  of  the  incision  is  about  opposite  to  the 
centre  of  that  bone  (Fig.  36). 

The  skin,  platysma,  supra-clavicular  nerves,  and  fascia  are 
divided  in  the  first  incision.  At  the  outer  end  of  the  wound 
care  must  be  taken  not  to  wound  the  cephalic  vein  and  the 
large  branch  of  the  acromio-thoracic  arter}-. 

The  cephalic  vein  should  be  exposed,  and  forms  a  useful 
guide  to  the  artery. 

The  pectoralis  major  is  divided  through  its  entire  thickness 
close  to  the  clavicle,  and  to  the  full  extent  of  the  original 
wound.  The  upper  edge  of  the  lesser  pectoral  should  be 
defined  and  drawn  down. 

The  costo-coracoid  membrane  must  now  be  dealt  with.  It 
should  not  be  torn  through,  but  should  be  divided  vertically 
near  to  the  coracoid  process.  The  cephalic  vein,  if  well 
brought  out,  will  indicate  the  position  of  the  axillary  vein. 
The  latter  vessel  is  readily  torn  in  freeing  a  way  through  the 
costo-coracoid  membrane. 

The  artery  is  now  exposed,  and  the  needle  should  be 
passed  from  the  vein.  The  vein  should  be  held  aside  Avith 
the  finger  while  the  needle  is  being  passed. 


131  OPERATIVE    SURGERY. 

It  must  be  remembered  that  the  vein  is  least  in  the  way 
when  the  arm  is  by  the  side. 

Comvient. — There  is  great  danger  of  tearing  the  axillary 
vein,  and  also  of  air  being  drawn  into  some  of  the  smaller 
veins.  If  the  pectoralis  minor  receive  a  shp  from  the  second 
rib,  the  area  of  the  operation  is  much  curtailed.  The  cord  or 
the  brachial  plexus  nearest  to  the  artery  may  be  mistaken  for 
that  vessel. 

The  operation  described  may  be  considered  as  a  modi- 
fication of  Chamberlaine's  original  proceeding. 

Delpech  made  an  obUque  incision  do^vnwards  along  the 
gap  which  separates  the  pectoralis  major  from  the  deltoid, 
the  wound  starting  from  the  clavicle.  The  two  muscles  were 
then  separated  from  one  another,  the  pectorahs  minor  divided 
near  to  the  coracoid  process,  and  the  vessel  dra\vn  outwards 
and  secured.     The  operation  is  needlessly  difficult. 

Guthrie  was  an  advocate  for  what  must  certainly  be  called 
a  fi'ee  incision.  His  incision  was  "  made  in  the  course  of  the 
axillary  artery,  through  the  integuments,  superficial  fascia,  and 
the  great  pectoral  muscle — in  fact,  through  the  anterior  fold  of 
the  armpit."  The  extent  of  the  wound  was  onl}^  limited  by  the 
position  of  the  proposed  hgature. 

Collateral  Circulation  after  Ligature  of  the  Axillary- 
Artery. 

1.  If  the  first  part  be  ligatured  above  the  origin  of  the 

acromio-thoracic,  the  collateral  circulation  will  be 
the  same  as  after  ligature  of  the  third  part  of  the 
subclavian. 

2.  If  the  third  part  be  secured  below  the  circumflex 

vessels,  the  condition  is  the  same  as  after  ligature 
of  the  brachial  above  the  superior  profunda. 

3.  Ligature  of  the  third  part  between  the  origins  of 

the  subscapular  and  the  two  circumflex. 

Above.  Below. 

Suprascapular  )  ^.^^^  Posterior  circumflex. 

Acromio-thoracic       ) 

4.  Ligature  of  the  third  part  above  the  origin  of  the 

subscapular.  The  same  anastomoses  as  just  given, 
with 


LIGATURE    OF   AXILLARY   ARTERY.  135 

Above.  Below. 

Long  Thoracic  > 

Inteicostals  f 

Posterior  Scapular  C  ^"^'^  Subscapular. 

Suprascapular  J 

Varieties  of  the  Axillary  Artery. 

1.  In  one  case  out  of  every  ten  (R.  Quain)  the  axillary 

gives  off  a  large  branch,  "which  Avill  be  most 
frequently  the  radial,  sometimes  the  ukiar,  less 
frequently  a  vas  aberrans,  and  very  rarely  the 
interosseous  artery. 

2.  A  trunk  may  arise  from  the  third  part  of  the  artery 

from  which  will  spring  the  subscapular,  the  two 
circumflex  and  the  two  profimda  arteries. 


136 


CHAPTER    III 

Ligature  of  the  Arteries  of  the  Head  and  Neck. 

THE   subclavian   ARTERY. 

Anatomy. — The  subclavian  artery,  starting  from  the  aorta 
on  the  left  side  and  the  innominate  on  the  right,  arches  across 
the  lower  part  of  the  neck  to  reach  the  axilla.  In  the  neck  it 
usually  reaches  to  the  height  of  a  point  on  a  level  with  the 
sixth  cervical  vertebra.  The  length  of  the  right  artery  is 
about  three  inches,  the  left  about  four.  The  latter  vessel  is  a 
little  smaller  than  the  right.  The  diameter  of  the  subclavian 
diminishes  from  11  m.m.  to  9  m.m. 

The  first  part  of  the  artery  is  considered  to  extend  from  the 
origin  of  the  vessel  to  the  inner  edge  of  the  anterior  scalene 
muscle.  The  second  part  is  that  which  hes  behind  the  anterior 
scalene  muscle,  and  the  third  part  is  that  beyond  the  muscle. 

The  right  subclavian  and  the  cervical  part  of  the  left  com- 
mence opposite  the  upper  part  of  the  sterno-clavicular  joint. 
The  jirst  part  of  the  artery  is  deeply  placed  beneath  the 
integimients,  the  platysma,  the  sterno-mastoid,  sterno-hyoid, 
and  sterno-thjrroid  muscles,  and  the  cervical  fascia.  It  is  near 
to  the  trachea,  is  in  contact  with  the  pleura  below  and  behind, 
and  is  in  close  relation  with  the  innominate,  internal  jugular 
and  vertebral  veins,  the  vagus,  recurrent  laryngeal,  cardiac  and 
sympathetic  nerves.  The  left  subclavian  is  also  in  relation 
with  the  thoracic  duct  and  the  phrenic  nerve.  From  this 
part  of  the  artery  arise  the  vertebral,  the  internal  mammary, 
and  the  thyroid  axis. 

The  second  part  of  the  artery  reaches  highest  in  the  neck, 
and  hes  between  the  anterior  and  middle  scalene  muscles. 

It  is  still  in  relation  with  the  pleura,  and  is  separated  from 
tlie  phrenic  nerve  by  the  anterior  of  the  two  muscles. 

The  superior  intercostal  artery  arises  from  this  part. 


LIGATURE    OF   SUBCLAVIAN  ARTERY.  137 

The  third  j)art  of  the  subclavian  represents  the  segment  of 
the  vessel  which  crosses  the  posterior  triangle  of  the  neck,  and 
which  is  nearest  to  the  surface.  It  is  the  part  to  which  the 
ligature  is  applied.  It  runs  in  a  triangle,  the  base  of  which  is 
formed  by  the  outer  edge  of  the  anterior  scalene  and  the  sides 
by  the  clavicle  and  omo-hyoid.  The  omo-hyoid  is  generally 
found  about  one  inch  above  the  clavicle  in  this  situation.  It 
may,  however,  be  found  ahnost  level  with  the  bone,  or  so  high 
up  as  not  to  be  encountered  in  the  oj^eration.  Much  depends 
upon  the  position  of  the  shoulder. 

The  third  part  of  the  artery  is  covered  by  the  integuments 
and  platysma,  by  the  cervical  fascia  and  a  fibrous  expansion 
which  stretches  from  the  omo-hyoid  to  the  clavicle.  It  rests 
upon  the  first  rib,  the  middle  scalene  muscle  is  behind  it, 
the  cords  of  the  brachial  plexus  are  above  it. 

The  last  cord,  derived  from  the  eighth  cervical  and  the 
first  dorsal,  is  nearest  to  the  artery.  The  little  nerve  to  the 
subclavian  muscle  crosses  in  front  of  the  vessel,  and  nearer 
to  the  surface  the  supra-clavicular  nerves  descend  in  front  of 
the  subclavian  triangle. 

The  subclavian  vein  hes  below  the  artery  and  anterior  to 
it.     It  passes  in  front  of  the  scalenus  anticus  (Fig.  37). 

The  external  jugular  vein  is  placed  in  front  of  the  artery, 
although  its  relations  to  the  vessel  vary  considerably.  It 
receives  in  this  region  the  transverse  cervical  and  suprascapu- 
lar veins,  which  may  form  a  plexus  over  the  subclavian  artery. 

The  suprascapular  artery  lies  behind  and  under  cover  of 
the  clavicle.  The  transverse  cervical  artery  crosses  beneath 
the  omo-hyoid  muscle  at  some  distance  above  the  main 
vessel.  No  branch  arises  normally  from  this  j)art  of  the 
subclavian. 

Indications. — A  ligature  has  been  applied  to  each  of  the 
three  parts  of  the  subclavian  artery.  So  far  as  surgical  ex- 
perience at  present  e;^tends,  it  may  be  said  that  the  operation 
is  only  justifiable  when  the  third  part  of  the  artery  is  con- 
cerned. 

A  ligature  has  been  applied  to  this  portion  of  the  vessel  in 
cases  of  axillary  aneurysm,  in  cases  of  wound,  and  in  instances 
of  haemorrhage  from  the  axilla.  It  has  been  applied  also  as  a 
distal  Hsrature   in   the  treatment  of  innominate  and   aortic 


138  OTEBATIVE    SURGERY. 

aneurysms,  and  as  a  preliminar}^  stej)  in  excision  of  the 
scapula,  in  the  removal  of  large  axillary  growths,  and  in 
amj^utation  of  the  entire  upper  hmb.  The  operation  on  the 
whole  may  be  considered  to  be  satisfactory,  although  the  risks 
of  secondary  haemorrhage  and  of  intra-thoracic  inflammation 
are  considerable.  These  risks  have  been  greatly  reduced  since 
wounds  have  been  treated  antiseptically.  The  mortahty  after 
Hgature  of  the  third  part  for  axillary  aneurysm  is  notably  high, 
death  following  frequently  fi'om  suppuration  of  the  sac  and 
secondary'-  haemorrhage.  Xorris  showed  that  in  sixty  examples 
of  this  operation  the  mortahty  was  forty-five  per  cent. 

Ligature  of  the  third  part  of  the  artery  was  first  attempted 
by  Su'  Astley  Cooper  in  the  spring  of  1809.  He  was  unable  to 
complete  the  operation.  In  the  autumn  of  the  same  year 
Ramsden  ligatured  the  artery  for  the  first  time  {Practical 
Observations:  London,  1811).  The  patient  died.  During 
succeeding  years  several  surgeons  carried  out  Ramsden's 
operation,  but  all  the  patients  died.  The  first  successful  case 
was  treated  by  Post,  of  New  York,  who  operated  in  September, 
1817  (Med.-Chir.  Trans.,  voL  ix.,  page  185).  The  first  success 
in  Great  Britaia  was  obtained  hj  Listen  in  1820  {Edin.  Med. 
a7ul  Surg.  Journ.,  voL  xvi,  page  348). 

The  first  part  of  the  subclavdan  was  first  ligatured  by 
Colles,  in  1818.  Ashhurst  has  collected  nineteen  examples  of 
this  operation,  but  not  a  single  patient  survived.  In  one  case, 
that  by  Mr.  Mitchell  Banks,  the  patient  survived  the  ligature 
thirt3'-six  da3's.  In  this  instance  the  innominate  had  ah'e<idy 
been  tied  (Jacobson's  "  Operations  of  Surgery,"  page  537). 

The  operation,  so  far  as  present  experience  goes,  may  be 
said  to  be  distinctly  unjustifiable.  No  artery  could  be  less 
favourably  placed  for  the  apphcation  of  a  Hgature.  It  is 
deeply  situated,  is  near  the  heart,  is  in  contact  with  the 
pleura,  is  surrounded  by  immense  veins,  and  is  in  intimate 
relation  with  such  nerves  as  the  vagus,  the  phrenic,  the 
recurrent  laryngeal,  and  the  cardiac.  Moreover  the  ligature 
is  apphed  about  a  part  of  the  vessel  where  numerous  large 
branches  are  arising. 

The  method  adopted  has  been  similar  to  that  carried  out 
in  exposing  the  innominate  artery. 

The  second  part  of  the  vessel  was  ligatured  by  Dupuytren. 


LIGATURE    OF   SUBCLAVIAN   AETERT. 


130 


He  has  liad  a  few  imitators,  but  no  patient  subjected  to  this 
operation  has  survived. 

Position. — (To  hgature  the  third  part.) — The  patient  Ues 
upon  the  back  close  to  the  edge  of  the  table,  with  the  thorax 
raised  and  the  head  extended  and  turned  to  the  opposite 
side. 

The  arm  should  be  pulled  well  do\\T2  and  fixed.  This 
latter  object  is  best  effected  by  passing  the  arm  behind  the 
back  whenever  that  is 
possible,  and  allowing 
it  to  remain  fixed  in 
that  posture.  The  opera- 
tor stands  in  front  of 
the  shoulder.  A  good 
hght  is  necessary. 

Ligature  of  the 
Third  Part  of  the  Sub- 
clavian Artery. 

Operation.  —  The 
slviu  over  the  posterior 
trianyie  havino-  been 
draAvn  do^Ti  with  the 
fingers  of  the  left  hand, 
an  incision  is  made 
through  it  down  to  the 
cla\Ticle.  By  adopting 
this    plan    a     risk    of 


wounding  the  external 


Fig.  36. — LIGATUEE  OF  THE  FIEST  PAET  OF  THE 
AXILLARY  AETEEY,  THE  THIED  PAET  OF  THE 
SUBCLAVIAN,  THE  COMMON  CAEOTID,  AJSD  THE 
LINGUAL. 


jugular  vein  is  avoided. 

The  incision,  which  is  transverse,  should  be  about  three  inches 
in  length,  and  when  the  traction  upon  the  skin  is  withdrawn 
should  he  about  half  an  inch  above  the  clavicle  (Fig.  36).  It 
should  extend  across  the  base  of  the  posterior  triangle  from  the 
trapezius  to  the  sterno-mastoid,  and  should  be  so  planned  that 
the  centre  of  the  wound  shall  correspond  to  a  point  about  one 
inch  to  the  inner  side  of  the  centre  of  the  clavicle.  This  first 
incision  divides  the  integuments,  the  platysma  and  the  supra- 
clavicular nerves,  with  possibly  a  vein  which  passes  over  the 
clavicle  to  connect  the  cephalic  vein  with  the  external  jugular. 
The  amount  of   trapezius   and  sterno-mastoid  exposed  will 


UU  OPERATIVE    SUBGEBY. 

depend  upon  tlie  extent  to  which  those  muscles  are  attached 
to  the  clavicle. 

The  deep  cervical  fascia  is  now  reached,  and  is  divided 
in  the  length  of  the  original  wound.  No  director  should  be 
employed.  If  the  surgeon  cannot  divide  the  fascia  without 
the  aid  of  this  dangerous  instrument  he  had  better  not  attempt 
the  operation.  The  external  jugular  vein  must  now  be  dealt 
with.  Very  probably  it  can  be  drawn  aside  and  may  be  held 
by  a  small  blunt  hook  towards  the  outer  angle  of  the  wound. 
If  it  obstruct  the  area  of  the  operation  in  a  more  determined 
manner,  it  may  have  to  be  divided  between  two  ligatures. 
Sometimes  when  an  actual  plexus  of  veins  exists  in  front 
of  the!  artery  much  difficulty  is  encountered.  All  bleeding- 
vessels  must  be  secured.  The  wound  throughout  should  be 
as  bloodless  as  possible. 

The  outer  margin  of  the  anterior  scalene  muscle  should 
next  be  defined,  and  the  position  of  the  omo-hyoid  made  out. 
The  latter  muscle,  if  at  all  in  the  way,  must  be  drawn  upwards. 
When  the  edge  of  the  scalene  muscle  has  been  made  plainly 
evident,  the  finger  should  be  passed  along  it  until  the  tubercle 
on  the  first  rib  is  encountered.  The  finger  will  now  be  in 
3ontact  with  the  artery,  and  its  pulsations  can  be  felt  (Fig.  37). 
The  vessel  will  be  found  actually  resting  upon  the  bone. 
A  Httle  carefid  dissection  will  clear  the  artery  and  bring  into 
view  the  lowest  cord  of  the  brachial  plexus. 

This  nerve  cord  should  be  systematically  exposed  by  a 
sUght  and  careful  dissection.  It  may  be  at  once  said  that  it 
has  been  the  source  of  some  of  the  more  serious  mistakes 
which  may  be  made  in  this  operation.  The  subclavian  vein 
will  be  seen  and  felt,  but  it  seldom  encroaches  much  upon 
the  field  of  the  operation. 

The  transverse  cervical  artery  runs  high  up,  and  will  prob- 
ably not  come  into  view.  The  suprascapular  artery  keeps 
under  cover  of  the  clavicle.  The  fascia  surrounding  the  sub- 
clavian is  fairly  substantial. 

The  needle  (unthreaded)  may  now  be  very  carefully  passed 
from  above  downwards  and  from  behind  forwards.  Its  course 
must  be  directed  by  the  forefinger  of  the  left  hand.  By  this 
finger  the  vein  is  protected  and  held  out  of  the  way.  If  the 
needle  be  passed  from  below — i.e.,  from  the  vein — it  is  easy  to 


LIGATURE    OF   SUBCLAVIAN    ARTERY.  141 

pick  up  the  last  cord  of  the  plexus  with  the  artery.  The  pleura 
has  been  wounded  by  a  needle  Avhich  has  been  carelessly 
passed. 

Comment. — The  incision  above  described  is  substantially 
the  same  as  that  carried  out  by  Ranisdon. 

The  operation  is  difficult,  and  requires  a  very  steady  hand 
and  a  very  perfect  control  over  the  scalpel  and  forceps.  The 
parts  should  be  cautiously  exposed  by  means  of  the  knife,  and 


E 
F  L  ^ 

Fig.    37. — LIGATtTEE  OP  THE  EIGHT  SUBCLAVIAN  (THIRD  PAET). 

A,  Cla\'icle ;  b,  Sterno-mastoid ;  C,  Trapezius  ;  D,  Omo-hyoid ;  E, 
Anterior  scalene  ;  F,  Cervical  fascia ;  a,  Subclavian  artery  ;  b, 
Subclavian  vein ;  e,  Ext.  jugular  vein ;  d,  Transverse  cervical 
artery  ;  1,  Brachial  plexus. 

not  by  means  of  tearing  and  rending  with  the  fingers  and 
blunt  instruments. 

One  author  advises  that  no  further  use  should  be  made  of 
the  knife  when  once  the  deep  fascia  has  been  divided.  The 
rest  of  the  operation  may  be  accomplished,  he  affirms,  by 
tearing.  This  procedure  is  uncouth,  unsurgical,  and  bar- 
barous. It  encourages  the  rending  of  the  many  veins  in 
the  vicinity,  the  displacement  of  the  tissues,  and  the  rupture 
of  the  pleura.  With  reference  to  this  plan  of  operating  by 
tearing,  however,  the  author  in  question  consoles  the  reader 
by  the  observation  that  "  herein  lies  the  difference  in  m}- 
teacliing  from  that  of  other  operators." 

In  order  to  obtain  sufficient  room,  portions  of  the  trapezius 
or  of  the  sterno-mastoid  may  have  to  be  cut. 

The  transverse  cervical  or  suprascapular  arteries  may  be  in 
the  way.    They  should  be  drawn  aside,  but  in  no  case  divided, 


142  OPEBATIVE    SUBGEBY. 

as  they  pla}^  a  most  important  part  in  the  collateral  circulation. 
These  arteries  have  been  injiirefl  during  the  operation,  as  havfe 
also  been  the  external  jugular  A'cin  and  the  phreni(3  nerve. 

If  the  neck  be  short  and  the  patient  stout,  the  difficulties 
of  the  operation  are  much  increased.  Great  difficulty  will 
also  be  experienced  when  the  veins  have  a  plexiform  arrange- 
ment or  are  engorged,  and  when  the  tissues  are  found  to  be 
cedematous  and  matted  together. 

The  pleura  has  been  several  times  wounded  in  passing  the 
needle,  and  in  many  of  the  fatal  cases  where  this  accident  is 
not  noted  the  patient  succumbed  to  intra-thoracic  inflamma- 
tion. Both  Listen  and  Green  passed  the  Ugature  around  the 
last  cord  of  the  brachial  plexus  by  accident.  South  has  seen 
the  posterior  scapular  artery  picked  up  and  mistaken  for  the 
subclavian. 

In  very  few  instances  does  the  subclavian  vein  appear  to 
have  been  wounded. 

Difficulties  may  be  caused  by  the  presence  of  a  cervical 
rib  or  by  an  abnormality  in  the  artery. 

Collateral  Circulation  after  Ligature  of  the  Third  Part 
of  the  Subclavian  Artery. 

Above.  Below. 

Suprascapular  )  w'th  i  Acromio-thoracic  and 

Posterior  scapular  '  ^  Subscapular. 

Internal  Mammary  )  (  Thoracic  and  Scapular 

Aortic  Intercostals  >  with            <  ,         ,         <•  .    -n 

^             ^  ,  t  i  branches  oi  Axillary. 

Superior  Intercostals  ^  ^ 

Varieties  of  the  Subclavian  Artery : — 

1.  Variations  in  the  origin  of  the  subclavian  have  little 

effect  upon  the  third  part  of  the  artery. 

2.  A  cervical  rib  may  exist,  and  the  artery  be  carried 

upon  it,  or  upon  the  fibrous  cord  in  which  such 
ribs  often  terminate  anteriorly. 

3.  The  artery  may  reach  as  high  as  one  inch  or  even 

(especially  on  the  right  side)  one  inch  and  a  half 
above  the  clavicle,  or  may  be  so  low  as  to  be  en- 
tirely under  cover  of  the  clavicle. 

4.  The    artery    may    perforate    the    anterior    scalene 

muscle,  and  in  rarer  cases  may  be  in  front  of  it. 


LIGATURE    OF   INNOMINATE   ARTERY.  143 

5.  The  posterior  scapular  artery,  and  more  lairely  the 
suprascapular,  may  arise  from  the  third  part  of  the 
artery. 

THE   INNOMINATE   ARTERY. 

Anatomy. — This  vessel  has  a  diameter  of  about  14  m.m., 
a  length  of  from,  one  to  two  inches,  and  is  roughly  repre- 
sented by  a  line  drawn  from  the  centre  of  the  manubrium  to 
the  sterno-clavicular  joint.  "  The  place  of  bifurcation  would, 
in  most  cases,  be  reached  by  a  probe  passed  backwards  through 
the  interval  between  the  sternal  and  clavicular  portions  of  the 
sterno-mastoid  muscle"  (Quain).  The  artery  may  divjide  at 
a  point  considerably  below  the  clavicle,  and,  less  frequently, 
at  a  point  above  it.  The  vessel  may  in  some  uncoivimon 
instances  give  off  the  thyroidea  ima,  or  even  the  internal 
mammary  or  bronchial  arteries. 

The  innominate  is  separated  from  the  sternum  by  the 
sterno-hyoid  and  sterno-thyroid  muscles,  the  remains  oi  the 
thymus  gland,  and,  near  its  root,  by  the  left  innominate  \%im. 

It  is  in  close  connection  with  the  trachea,  and  in  still  more 
intimate  relation  with  the  pleura.  On  the  right  side  arc  the 
right  innominate  vein  and  the  vagus  nerve ;  on  the  left  aiv3  the 
inferior  th}Toid  veins  and  the  left  carotid  artery. 

Indications. — This  vessel  has  been  secured  for  the  relief  of 
carotid  and  subclavian  aneurysms.  The  results,  however,  of 
the  operation  have  been  such  that  it  is  questioned  whether  it 
is  to  be  considered  as  a  justifiable  surgical  procedure. 

So  far  as  present  experience  extends  as  to  the  circumstances 
which  influence  the  success  of  the  Ugature  of  large  arteries,  it 
would  appear  that  Hgature  of  the  mnominate  carries  with  it 
a  better  prospect  of  success — other  things  being  equal — than 
does  hgature  of  the  first  part  of  the  subclavian.  It  is  true 
that  the  innominate  is  deeply  and  inconveniently  placed ;  it  is 
true  that  the  operation  is  exceedingly  difficult ;  it  is  true  that 
the  vessel  is  nearer  to  the  heart ;  but,  on  the  other  hand,  the 
trunk  gives  off  normally  no  branches,  there  is  room  for  the 
apphcation  of  the  ligature,  and  the  vessel  is  not  in  so  intimate 
relation  with  such  nerves  as  the  vagus,  the  sympathetic,  the 
phrenic,  and  the  recurrent  laryngeal,  as  is  the  first  part  of  the 
subclavian. 


144  OPERATIVE    8UBGEBY. 

It  would  appear  (Ashhurst)  that  this  ligature  has  been 
carried  out  at  least  twenty-four  times :  but  only  two  patients 
have  survived  the  operation.  One  of  these  cases  was  under 
the  care  of  Dr.  Smyth,  of  Ncav  Orleans  (Syd.  Soc.  Bien.  Retros., 
1865-6,  page  346).  The  patient,  after  exhibiting  symptoms  of 
secondar}''  haemorrhage,  recovered  and  hved  ten  j-ears.  In  the 
second  case  the  operation  was  performed  by  Mr.  Mitchell 
Banks  (Jacobson's  "  Operations  of  Surgery,"  page  529),  and  the 
patient  hved  fifteen  weeks. 

In  ah  the  fatal  cases  death  has  followed  from  secondary 
hiKmorrhage.  Some  patients  have  survived  the  operation 
many  days.  Thus  Thompson's  jDatient  lived  forty-two  days, 
and  Graefe's  sixty-seven  daj^s.  Both  ultimately  succumbed 
to  secondary  haemorrhage. 

Several  of  the  operations  included  m  the  hst  have  been 
performed  within  quite  recent  times,  and  under  the  most 
approved  antiseptic  principles,  but  the  results  have  not  been 
substantially  modified. 

Tlte  great  danger  is  from  secondary  hEemorrhage,  which 
takes  place  apparently  always  from  the  vessel  on  the  distal 
side  of  the  ligature.  Other  complications  have  appeared,  such 
iis  suppurative  cellulitis,  pericarditis,  cerebral  embolism,  lung 
troubles,  &c. 

The  first  operation  was  performed  by  Dr.  Mott,  of  New 
York,  in  1818,  for  subclavian  aneurysm.  The  patient  died 
on  the  26th  day  of  secondary  heemorrhage  {Med.  and  Surg. 
Register  of  New  York,  1818,  page  8).  An  excellent  summary 
of  the  chief  cases  is  given  by  Mr.  W.  G.  Spencer  in  a  paper 
published  in  The  British  Medical  Journal,  July  13th,  1889. 

Operation. — The  position  of  the  patient  and  of  the  surgeon 
is  the  same  as  in  the  previous  operation.  A  good  light  is  re- 
quired, and  means  should  be  at  hand  for  illuminating  the 
depths  of  the  womid.  Several  aneurysm  needles  of  different 
patterns,  and  presenting  several  varieties  of  curve,  should  be 
provided. 

The  operation  here  described  is  identical  in  all  essential 
particulars  with  the  original  procedure  of  Mott. 

An  incision  is  made  along  the  upper  border  of  the  innsi? 
third  of  the  clavicle,  and  a  second  cut  follows  the  anterior 
ed^e  of  the  sterno-mastoid  muscle.     Each  incision  is  at  least 


LIGATURE    OF   INNOMINATE    ARTEIiY.  145 

three  inches  in  length,  and  they  join  one  another  at  an  acute 
angle. 

The  skin  and  superficial  structures  having  been  divided,  the 
flap  marked  out  is  dissected  up. 

The  stemo-hyoid  and  sterno-thyroid  muscles  are  now 
divided  close  to  the  sternum,  together  with  so  much  of  the 
sterno-mastoid  as  is  exposed  in  the  wound. 

Care  must  be  taken  of  the  anterior  jugular  vein,  which 
passes  behind  the  last-named  muscle  near  its  origin.  The 
vein  is  inconstant  in  size,  and  should  be  divided  between  two 
ligatures.  The  deep  cervical  fascia  is  exposed  and  divided  in 
the  lines  of  the  superficial  wound.  The  operator  now  seeks 
for  the  common  carotid  artery,  and  having  opened  the  sheath 
of  that  vessel  as  Ioav  do"\\Ti  as  possible,  he  follows  it  until  he  is 
led  to  the  bifurcation  of  the  mnominate. 

"  It  is  now,"  writes  Mr.  Jacobson,  "  that  the  real  difficulties 
will  be  met  with.  (1.)  Owing  to  engorgement  of  the  venous 
circulation,  increased  by  the  annesthetic,  the  internal  jugulai' 
and  innominate  vein  may  be  so  much  enlarged  as  to  protrude 
through  the  wound.  (2.)  An  aneurysm  may  have  reached 
under  the  artery  and  flattened  it  out  so  as  to  make  it  ditficult 
of  recognition.  The  cellular  tissue  around  the  vessel  and  be- 
tween it  and  the  sternum  may  be  so  matted  with  adhesions, 
as  to  make  it  diflicult  to  define  the  artery  and  its  important 
relations  on  the  right  side — viz.,  vagus,  pleura,  and  right 
innominate  vein.  (3.)  The  artery  itself  may  be  enormously 
diseased  and  expanded.  In  tracing  do^v^l  the  innominate 
itself,  the  surgeon  must  keep  his  steel  director  most  carefully 
on  the  front  of  the  artery.  In  following  the  vessel  down  behind 
the  sternum  in  order  to  find  a  site  for  his  ligature,  he  wiU  be 
aided  by  shghtly  flexing  the  head  and  by  a  laryngeal  mirror. 
The  cleaning  the  artery  must  be  done  with  the  utmost  caution, 
especially  on  the  outer  side,  owing  to  the  important  structures 
lying  there ;  of  these  the  innominate  vein  and  the  vagus  may 
be  drawn  outside,  but  it  is  only  by  keeping  the  director  or 
needle-point  very  close  to  the  artery  here  that  injury  to  the 
pleura  can  be  avoided." 

The  needle  should  be  passed  from  without  in,  and  a  Httle 
from  below  upwards,  so  as  to  avoid  the  pleura  as  far  as 
possible. 


146  OPERATIVE    SUBGEBY. 

In  order  to  avoid  the  chief  danger  of  the  operation — 
secondary  htemorrhage  from  the  distal  side  of  the  Hgature — 
the  common  carotid  and  the  vertebral  should  be  hgatiired  at 
the  same  time.  The  procedure  involves,  therefore,  the 
securing  of  three  arteries. 

No  drainage-tube  should  be  used,  and  every  possible 
means  should  be  taken  to  bring  about  a  primary  healing  of 
the  wound. 

Comment. — Much  has  been  said  upon  the  subject  of  the 
best  ligature  to  use  in  this  operation.  In  the  two  successful 
cases  silk  and  tendon  were  respectively  employed.  So  far  as 
it  is  possible  to  form  an  opinion,  the  precise  nature  of  the 
ligature  would  appear  to  be  a  matter  of  no  very  great  import- 
ance. No  substantial  objection  has  been  urged  against  well- 
prepared,  carefully  selected,  chromicised  catgut.  The  tendon 
ligature  has  much  to  recommend  it. 

Flat  Ugatures  can  hardly  be  said  to  have  established  un- 
doubted claims  of  superiority.  The  flat  Hgature  is  clumsy, 
and  is  not  readily  passed  around  the  artery.  The  knot  formed 
is  very  bulky.  If  tightly  applied,  the  whole  of  the  ligature 
does  not  he  flat  upon  the  artery,  but  near  the  knot  it  will  be 
usually  found  to  be  cutting  into  the  vessel  with  its  edge.  It 
can  only  be  said  of  these  Hgatures  that  they  are  flat  before 
apphcation.  It  has  not  been  shoAvn  that  they  are  free  from 
the  objection  of  becoming  loosened  on  account  of  the  knot 
becoming  soft  or  untied. 

In  Mr.  May's  case  of  ligature  of  the  innominate,  the  flat 
ligature  passed  around  the  vessel  snapped  in  the  tying,  and 
this  very  serious  accident  was  repeated  twice.  He  substituted 
for  the  flat  ligature  a  cord  made  of  Ave  or  six  medium-sized 
tlireads  of  catgut.  The  knot  was  very  large,  and  he  thinks 
that  the  pressure  of  it  upon  the  vessel  was  the  cause  of  the 
secondary  hiemorrhage  of  which  the  patient  died.  Mr.  Holmes 
is  disposed  to  regard  the  flat  ligature  favourably. 

In  Mr.  Thompson's  case  of  ligature  of  the  innominate,  the 
patient  lived  six  weeks.  An  ox-aorta  ligature  was  used.  The 
vessel  was  found  to  be  obliterated,  and  the  ligature  had  en- 
tirely (lisapjx'urcd. 

Collateral  Circulation  after  Ligature  of  the  Innominate 
Artery  (as  given  by  MacCormac). 


LlGATUliE    OF    VERTEBRAL    ARTERY. 


147 


Trunk. 


Head. 


Cardiac  side.  Distal  side. 

First  aortic  intercostal         with     Superior  intercostal  of  subclavian. 

,.    .    .  .  ,  .,,    (Thoracic  branches  of  axillary,   and 

Upper  aortic  mtercostals      with  .'  ,  i      <•  •   ^         i 

■^  ^  (^      mtercostals  oi  internal  mammary. 

'  ,,,        .  .,,    ( Musculo-phrenic   of    internal   mam- 

Phrenic  with  \  ^ 

\      mary. 

^  .       ,  .  •j.x   \  Superior  episrastric  of  internal  mam- 

Deep  epigastric  with         ^  ^  ° 

*     ^  °  (       mary. 

■  Free  communication  of  verteLials  and  internal  carotids  of  opposite  sides 
inside  the  skull.      Communication  of  branches  of  opposite  external 
.      carotids  in  middle  line  of  the  face  and  neck. 


h 
B.. 
D 


.--^ 


THE   VERTEBRAL   ARTERY   (ill.). 

Anatomy. — The  vertebral  artery  is  tlie  size  of  the  uhaar, 
and  arises  about  one-third  of  an  inch  to  the  inner  side  of  the 
anterior  scalene 
muscle  from  the 
U]3per  and  back 
part  of  the  first 
part  of  the  sub- 
clavian artery. 

The  vessel 
passes  upwards, 
and  a  httle  back- 
wards and  out- 
wards, and  enters 
the  foramen  in  the 
transverse  process 
of  the  sixth  cervi- 
cal vertebra.  It 
runs  in  the  gap 
between  the  an- 
terior scalene 
muscle  and  the 
Iqngus  colli.  The 
internal  jugular 
vein  and  the  ver- 
tebral vein  He  m 
fi'ont  of  it.  The 
inferior  thyroid  artery  crosses  it  anteriorly,  as  does  also  the 
thoracic  duct  upon  the  left  side  (Fig.  38). 
K  2 


Fig.    38.— ANATOMY    OF    THE  VEETEBEAL    AND    INFERIOE 

THYEOiD  AETEEiES.    {Modijicd  fvom  Godlee'' s  Atlas.) 

A,  Thyroid  glard  ;  B,  Trachea  ;  c,  Clavicle  ;  D,  Sterno- 
thyroid ;  E,  Scalenus  medius ;  v,  Longus  colli,  with 
sympathetic  nerve  upon  it  ;  G,  Scalenus  anticus  (cut)  ; 
H,  Subclavius ;  I.  Transverse  process  of  Gtli  cervical 
vertebra  ;  J,  Brachial  plexus  ;  a,  Left  innominate  vein 
receiving  internal  jugular  ;  b,  Ext.  jugular  vein  enter- 
ing subclavian  vein ;  c,  Common  carotid  artery,  ^vith 
vagus  nerve  to  its  inner  side  ;  d,  Subclavian  artery 
crossed  by  nerve  to  subclavius  i.  Vertebral  artery 
and  vein ;  /,  Inferior  thyroid  artery. 


148  OPERATIVE    SURGERY. 

The  vessel  lies  uj)on  the  transverse  process  of  the  seventh 
cervical  vertebra,  and  the  cord  of  the  sympathetic  descends 
behind  it.  The  vertebral  is  accompanied  by  a  plexus  from  the 
inferior  cervical  ganghon. 

The  accessible  part  of  the  artery  measures  about  one  inch 
and  a  quarter. 

Indications. — The  vertebral  has  been  ligatured  in 
cases  of  injury,  and  also  in  a  few  instances  of  traumatic 
aneurysm. 

It  has  been  ligatured — with  other  arteries — in  the  treat- 
ment of  aortic  and  innominate  aneurysms  by  the  distal 
method,  and  has  been  secured  as  a  precaution  after  Hgature 
of  the  innominate.  At  one  time  hgature  of  this  vessel  was 
practised  as  a  means  of  treating  epilepsy ;  the  operation  was, 
however,  soon  abandoned  as  useless.  It  was  carried  out  in 
thirty-six  cases  of  epilepsy  by  Alexander,  of  Liverpool ;  out  of 
this  number  three  patients  died. 

The  vessel  was  first  hgatured  by  Smyth,  of  New  Orleans, 
in  1864. 

Operation. — The  position  of  the  patient  and  of  the  surgeon 
is  the  same  as  in  the  operation  upon  the  third  part  of  the 
subclavian  (page  139). 

A  good  light  is  needed  on  account  of  the  great  depth 
of  the  wound. 

An  incision,  three  inches  in  length,  is  commenced  at  the 
clavicle,  and  is  carried  upwards  along  the  outer  or  posterior 
edge  of  the  sterno-mastoid  muscle.  The  skin  and  superficial 
tissues  are  divided,  and  especial  care  is  taken  to  avoid  wound- 
ing the  external  jugular  vein.  The  deep  fascia  having  been 
severed,  the  sterno-mastoid  is  exposed,  and  with  the  jugular 
vein  is  drawn  inwards. 

It  will  probably  be  necessary  to  divide  some  part  of 
the  clavicular  attachment  of  the  sterno-mastoid  close  to  the 
bone.  The  operator  now  del^nes  the  scalenus  anticus,  and 
makes  evident  the  interval  between  that  muscle  and  the  longns 
colli  With  the  finger  he  should  make  out  the  position  of 
the  common  carotid  artery  and  internal  jugular  vein,  and 
define  the  transverse  processes  of  the  seventh  and  sixth 
cervical  vertebrae.  The  process  of  the  latter  vertebra  forms  a 
good  guide,  and  below  it  the  pulse  of  the  artery  should  be 


LIGATURE    OF   INFERIOR    THYROID    ARTERY.        149 

felt.  The  various  structures  encountered  must  be  carefully 
displaced  to  one  or  other  side. 

The  vertebral  vein  lies  in  front  of  the  artery,  and  shoidd 
be  pushed  aside.  Care  mu&t  be  taken  not  to  damage  the 
inferior  thyroid  vessels,  the  pleura,  or,  on  the  left  side,  the 
thoracic  duct  The  phrenic  nerve  need  not  be  exposed. 
The  needle  is  passed  from  without  inwards. 

With  regard  to  certain  pupil  phenomena  attending  the 
operation,  Sir  W.  MacCormac  thus  writes :  "  Immediate  con- 
traction of  the  corresponding  pupil,  due  to  interference  with 
the  dilating  fibres  of  the  cervical  sympathetic,  is  of  very  con- 
stant occurrence,  and  ma}^  be  regarded  as  a  pretty  certain  in- 
dication that  the  vessel  has  been  secured.  Two  small  nerves 
from  the  inferior  cervical  ganglion,  at  first  a  little  separated 
from  the  artery,  are  afterwards  very  closely  applied  to  it. 
When  these  are  included  in  the  loop  of  the  ligature,  the  con- 
traction of  the  pupil  will  continue  for  a  considerable  time.  A 
temporary  contraction  will  occur  when  the  nerves  are  excluded, 
because  of  the  almost  unavoidable  irritation  to  which  they 
are  subjected  during  the  steps  of  the  operation." 

Goviment. — The  ligature  of  this  artery  is  a  matter  of  no 
Uttle  difficulty.  The  greatest  care  must  be  taken  to  avoid 
injury  to  the  various  unportant  structures  which  He  adjacent 
to  the  vessel.  Both  the  inferior  thyroid  and  the  ascending 
cervir-al  arteries  have  been  mistaken  for  the  vertebral. 

THE    INFERIOR   THYROID   ARTERY   (iV.). 

Anatomy. — This  vessel  arises  from  the  thyroid  axis  at  the 
inner  margin  of  the  anterior  scalene  muscle.  It  passes 
upwards  in  front  of  the  vertebral  artery  and  longus  colli 
muscles,  and  then  bending  inwards  and  a  httle  downwards, 
passes  behind  the  common  carotid,  the  internal  jugular  vein, 
the  vagus,  and  the  sympathetic  (Fig.  38).  The  middle  cervical 
ganglion  rests  upon  it.  The  ascending  cervical  branch  arises 
from  the  ve^jooi  just  as  it  is  about  to  pass  behind  the  carotid. 
The  ligature  is  applied  to  the  artery  on  the  distal  side  of  this 
branch. 

The  recurrent  laiyngeal  nerve  is  in  close  relation  to  the 
artery  at  its  termination,  and  is  nearly  parallel  to  it  at  its 


liO  OPERATIVE    SURGERY. 

comiiienceinent.  The  thoracic  duct  passes  in  front  of  the 
root  of  the  left  artery. 

The  inferior  th3roid  may  arise  direct  fr'oni  the  subclavian, 
or  have  origin  from  the  common  carotid  or  vertebral.  It  may 
be  double,  or  entirely  absent. 

The  size,  course,  and  situation  of  the  vessel  vary  very 
greatly  in  cases  of  bronchocele. 

Indications. — The  vessel  is  secured  as  a  preliminary 
measure  in  removing  the  thjToid  body,  and  in  cases  of  injury. 
It  has  been  Hgatured  also,  together  with  the  superior  thyroid, 
for  the  purpose  of  arresting  the  growth,  or  of  diminishing  the 
size,  of  a  bronchocele.  The  very  free  anastomoses  between 
the  thyroid  vessels,  and  the  dangers  of  the  procedure,  have 
rendered  this  measure  very  unsatisfactory.  {See  article  by 
AVcilfler,  Wien.  Med.  Woch.,  1886,  and  summary  of  thirty- 
one  cases.) 

Operation. — An  incision,  three  inches  in  length,  is  made 
along  the  inner  edge  of  the  lower  part  of  the  sterno-mastoid 
muscle,  just  as  in  hgature  of  the  common  carotid  low  doAvn. 
The  wound  reaches  to  the  clavicle.  The  sterno-mastoid  is 
exposed  and  drawn  outwards,  the  carotid  artery  and  its  vein 
are  reached  and  are  drawn  carefully  outivards.  The  surgeon 
now  seeks  for  the  transverse  process  of  the  sixth  cervical 
vertebra,  and  a  little  below  that  the  artery  may  be  discovered, 
passing  imvards  from  behind  the  carotid  (Fig.  38).  It  is  liga- 
tured close  to  the  carotid,  and  in  this  way  the  immediate 
neighbourhood  of  the  recurrent  larjmgeal  nerve  is  avoided. 

THE   COMMON   CAROTID   ARTERY   (l.). 

Anatomy.— The  right  common  carotid  commences  at  the 
level  of  the  sterno-clavicular  articulation,  and  the  cervical 
part  of  the  left  may  be  considered  to  commence  at  the  same 
point.  The  vessel  bifurcates  opposite  to  the  upper  margin  of 
the  thyroid  cartilage,  on  a  level  with  the  third  cervical 
vertebra.  The  omo-hyoid  crosses  the  carotid  opposite  to  the 
lower  margin  of  the  cricoid  cartilage,  on  a  level  with  the  sixth 
cervical  vertebra. 

The  vessel  below  the  omo-hyoid  is  deeply  placed,  being 
covf-rcd  in  front  by  the  skin,  platysma,  fascia,  sterno-mastoid, 
sterno-hyoid,  and  sterno-thyroid  muscles.     This  part  of  the 


LIGATURE    OF    COMMON    CAROTID    ARTERY.         151 

artery  may  also  be  overlapped  by  the  thyroid  body.  The 
anterior  jugular  vein  passes  in  front  of  it,  and  the  inferior 
thyroid  artery  and  recurrent  laryngeal  nerve  behind  it. 

The  vessel  above  the  orao-ltyold  is  superiicial,  being  covered 
only  by  the  skin,  platysma,  and  cervical  fascia,  and  overlapped 
by  the  inner  margin  of  the  sterno-mastoid  muscle.  This  part 
of  the  artery  is  crossed  by  the  sterno-mastoid  branch  of  the 
superior  thyroid  artery,  and  by  the  superior  thyroid  vein.  The 
middle  thyroid  vein  will  usually  cross  the  carotid  with  the 
omo-hyoid  muscle.  The  superior  thyroid  vein  is  often  double, 
and  may,  in  some  cases,  form  a  species  of  plexus  in  front  of 
the  carotid. 

Along  the  inner  border  of  the  sterno-mastoid,  below  the 
hyoid  bone,  a  vein  generally  runs  which  serves  to  connect  the 
facial  vein  Avith  the  anterior  jugular. 

Behind  the  common  carotid,  in  its  entire  course,  are  the 
cervical  vertebrae,  the  longus  colli  muscle,  and  the  sympathetic 
nerve.  Above  the  level  of  the  cricoid  cartilage,  the  rectus 
capitis  anticus  major  muscle  is  also  posterior  to  the  artery. 

The  carotid  sheath  is  derived  from  the  cervical  fascia,  and 
is  very  substantial.  It  encloses  the  artery,  the  internal  jugular 
vein,  and  the  vagus  nerve.  Each  of  the  three  has  its  own 
especial  investment.  The  nerve  is  posterior  to  both  the  artery 
and  the  vein,  and  its  canal  lies  in  the  septum  which 
separates  these  two  vessels.  The  vein  is  to  the  outer  side  of 
the  artery — on  the  right  side  the  two  become  a  little  separated 
at  the  root  of  the  neck,  while  on  the  left  side  the  vein  over- 
laps the  artery  shghtly  in  that  position.  The  right  jugular 
vein  is  larger  than  the  left,  and  the  combined  sectional  areas 
of  the  two  jugular  veins  are  to  those  of  the  carotids  as  twenty 
to  eleven.  The  descendens  noni  nerve  descends  alons:  the 
front  of  the  carotid  sheath,  inclining  gradually  from  the  outer 
to  the  inner  side.  The  nerve  frequently  runs  within  the  sheath. 
The  sympathetic  nerve  is  close  to  the  carotid  sheath  behind. 

Line  of  the  Artery. — The  course  of  the  common  carotid  is 
represented  by  a  line  drawn  from  the  sterno-clavicular  articu- 
lation to  a  point  midway  between  the  angle  of  the  jaw  and 
the  tip  of  the  mastoid  process. 

A  valuable  guide  to  the  artery,  at  about  the  point  of 
crossing  of  the  omo-hyoid  muscle,  is  afforded  by  Chassaignac's 


152  OPERATIVE    SURGERY. 

"carotid  tubercle."  This  is  the  costal  process  of  the  sixth 
cervical  vertebra,  and  the  artery  lies  directly  over  it.  It  is  to 
be  f  "und  about  two  and  a  half  inches  above  the  clavicle. 

Indications. — The  common  carotid  has  been  tied  for  many 
different  conditions.  It  has  been  ligatured  on  account  of 
wound,  on  account  of  haemorrhage  arising  from  definite 
branches  of  the  external  carotid  (e.g.,  the  superior  thyroid, 
Ungual,  temporal),  and  on  account  of  bleeding  generally  from 
parts  on  the  distal  side  of  the  vessel.  Thus  the  carotid  has 
been  secured  in  cases  of  hemorrhage  from  the  orbit,  the 
middle  ear,  the  tongue,  the  mouth,  the  tonsil,  the  maxillae, 
and  in  cases  of  cut  throat,  gunshot  wound,  and  the  Hke. 

A  Hgature  has  been  appUed  in  cases  of  aneurysm  of  the 
external  or  internal  carotid,  in  intracranial  aneurysm,  and  in 
examples  of  angeiomata  involving  the  branches  of  the  carotid. 
The  distal  hgature  has  been  apphed  to  the  vessel  in  some 
instances  of  anemrysm  of  the  aorta  or  innominate  Sirtery.  The 
common  trunk  has  been  secured  to  restrain  haemorrhage,  and 
to  limit  growth  in  the  case  of  certain  malignant  tumours,  and 
to  check  bleeding  during  the  removal  of  such  growths.  The 
ligature  of  the  carotid  as  a  means  of  treating  epilepsy  has  been 
abandoned  as  useless. 

I  haT'C  advocated  the  apphcation  of  a  temporary  hgature 
or  loop  to  the  common  carotid  in  instances  where  a  per- 
manent occlusion  of  the  artery  is  not  essential  (Lancet, 
Januarj',  1888). 

The  common  carotid  appears  to  have  been  first  secured 
for  haemorrhage  by  Abernethy,  in  1798  ("  Surgical  Works," 
voL  ii).  The  patient  died.  The  hgature  was  successfully 
applied  (for  haemorrhage)  in  1803  by  Fleming  {Med.-Chir. 
Joumrjd,  vol  iil).  Astley  Cooper  was  the  first  surgeon  to 
employ  ligature  of  the  common  carotid  as  a  means  of  treating 
aneurysm.  His  first  operation  was  performed  in  1805,  and 
ended  fatally  (Med.-Chir.  Trans.,  vol.  i.).  His  second  case 
(1808)  recovered. 

The  common  carotid  may  be  secured  at  any  part  of  its 
course  in  the  neck  The  operations  resolve  themselves,  hoAv- 
ever,  into  ligature  above  the  omo-hyoid  muscle  and  ligature 
below  it.  The  former  situation  is  in  every  respect  to  be  pre- 
ferred.    Below  the  muscle  the  vessel  is  deeply  placed,  and 


LIGATURE    OF    COMMON    CAROTID    ARTERY.         153 

has  more  complicated  relations  to  structures  of  importance. 
Farabeuf  has  well  said  that  "  below  the  omo-hyoid  muscle 
tlie  deaths  are  more  numerous  tlian  the  recoveries;  above,  the 
recoveries  preponderate  over  the  deaths." 

Position. — The  patient  lies  upon  the  back,  close  to  the 
edge  of  the  table,  Avith  the  shoulders  raised  and  the  hand  of 
the  affected  side  placed  behind  the  back.  The  chin  shoidd  be 
drawn  up  and  the  head  turned  a  httle  to  the  opposite  side. 
The  surgeon  stands  upon  the  side  exposed  for  operation. 

.  Ligature  at  the  Place  of  Election  (above  the  Omo- 
hyoid Muscle). — Operation. — The  position  of  the  cricoid  carti- 
lage having  been  defined,  and 
the  situation  of  the  superficial 

veins  made  evident,  an  incision,                 .    "^             ,a 
about  three  inches   in   length,                    */4*K* 
is  made  in  the  hne  of  the  ar-         b         jT^  ^^ 
tery,  and  is  so  placed  that  its                       ^^^. 
centre  is  on  a  level  with    the                  fP'^   ^ 
cricoid  cartilage  (Fig.  39).  ^  I''  ^^^  ^i        " ^ 

The  skin  and  platysma  hav-      -,^5        Wig  'P^'ij\  "" 

ing  been  incised  (together  with  ^    \T%^       ^ 

branches  of  the  superficial  cer-     ^'****^'''?^    i^/~  '  1  '^ 

vical  nerve),  the  surgeon  divides  ^SkL^^^v 

the  deep  fascia  along  the  ante-      *"  "^^^^  J'^ 

rior  border  of  the  stemo-mastoid  ^\^^    i 

muscle.      Along   this  border  a         ^  ^'W' 

communicating    vein    between  /V 

the     facial     and    the    anterior 

1  1  .  -,1  rri.  Fig.  39.— LIGATrHEOF  THE   RIGHT  COM- 

jugular  may  be  met  with.  Ihe  t,„.^  carotiu  above  the  omo- 
edge  of  the  muscle  is  defined,        hyoid. 

nnrl    k   fnllnwprl    nntil    thp   nmn  ^-  Platysma;    B,   Cervical  fascia;    c, 

ana    is   lOllOWea   until   ine   OmO-  stemo-mastoid  ;  d.  Omo-hyoid ;  a. 

hyoid      muscle      is      made      out.  Common  carotid ;  6,  Sterno-mastoid 

rrn                       -11              f      ^  '  artery ;    c,    Sup.    thyroid   vein ;    d, 

ihe      superior      border     01     this  internal  jagular  vein. 

structure  must  then  be  well  ex- 
posed, and  the  angle  at  which  the  two  muscles  meet  be  clearly 
demonstrated.     The   sterno-mastoid  may   be   drawn   a  Httle 
outwards,  and  the  omo-hyoid  downwards. 

The  pulsations  of  the  artery  should  now  be  sought  for,  and 
the  vessel  can  usually  be  easily  detected,  as  it  crosses  the  con- 
spicuous "carotid  tubercle." 


154  OPERATIVE    SURGEBY. 

The  artery  is  very  mobile,  and  slips  readily  to  and  fro 
under  the  linger.  If  the  pulse  be  feeble  it  may  present  the 
physical  characters  of  a  fiat  cord. 

In  exposing  the  sheath  of  the  artery,  care  must  be  taken 
to  avoid  the  sterno-mastoid  vessel  and  the  superior  or  middle 
th}Toid  veins. 

The  sheath  should  be  opened  wpon  the  inner  side,  and 
precaution  taken  not  to  damage  the  descendens  noni  nerve. 
Holding  the  sheath  by  the  inner  lip  of  the  wound  which  has 
been  made  in  it,  the  surgeon,  with  an  unthreaded  aneurysm 
needle,  should  clear  the  artery  upon  its  inner  side.  Holding, 
then,  the  outer  lip  of  the  sheath  in  the  forceps,  the  outer  side 
of  the  vessel  can  be  cleared.  By  shifting  the  forceps  as 
required,  the  whole  circumference  of  the  artery  can  be 
separated  from  its  sheath.  This  process  must  be  carried 
out  with  gTeat  care  and  with  thoroughness. 

The  needle  is  passed  from  wdthout  inwards,  is  then 
threaded  and  withdrawn,  bringing  the  Hgature  with  it. 

Corainent. — In  uncomplicated  cases  the  operation  is  very 
simple.  If  the  tissues  are  matted  together,  or  are  encroached 
upon  by  j^us  or  blood,  or  are  displaced  by  a  tumour  or  groAvth, 
the  procedure  may  be  attended  with  no  Httle  difficulty  and 
risk. 

If  the  head  be  turned  too  much  to  the  opposite  side, 
the  sterno-mastoid  is  carried  unduly  far  over  the  Sbvtery,  and 
the  border  of  the  muscle  may  be  missed. 

The  ojDeration  may  be  much  complicated  by  the  presence 
of  large  or  distended  veins.  The  internal  jugular  vein  is  of 
considerable  size,  is  very  thin,  and  is  readily  wounded.  Its 
proportions  are  influenced  by  the  respiratory  movements,  and, 
when  the  breathing  is  embarrassed,  it  becomes  at  one  time 
enormously  swollen,  and  at  another  moment  flat  and  com- 
paratively small. 

The  needle  uuist  be  passed  with  great  care.  The  artery 
has  been  transfixed  by  a  needle  which  has  been  very  roughly 
used.  The  descendens  noni,  the  pneumo-gastric,  and  even  the 
sympathetic  cord,  have  been  accidentally  included  in  the 
Hgature. 

2.  Ligature  below  the  Omo-hyoid  Muscle. 

Operatiun. — The  position  of  the  patient  is  the  same  as  in 


LIGATURE    OF    COMMON    CAROTID    ARTERY.         155 

the  previous  operation.  The  incision  is  three  inches  in  length, 
is  in  the  Hne  of  the  artery,  and  is  so  disposed  as  to  commence 
a  little  below  the  level  of  the  cricoid  cartilage,  and  end  a  little 
above  the  sterno-clavicular  joint.  It  follows  thf  inner  border 
of  the  sterno-mastoid  muscle.  Care  must  be  taken  to  avoid 
the  comniiuiicating  vein  from  the  facial,  already  described, 
and  also  the  anterior  jugular  vein. 

The  sterno-mastoid  is  exposed  and  dra\\ai  outwards.  The 
sterno-hyoid  and  sterno-thyroid  muscles  are  likewise  made 
evident,  and  are  drawn  inwards.  The  omo-hyoid,  if  seen, 
is  relegated  to  the  upper  part  of  the  wound. 

It  may  be  necessary  to  divide  the  sternal  part  of  the 
sterno-mastoid,  and  the  whole  or  parts  of  the  sterno-hyoid 
and  sterno-thyroid  muscles,  especially  if  the  ligatiu'e  has  to 
be  applied  as  low  doAvn  as  possible.  Retractors  are  needed 
to  draw  the  muscles  aside,  and  a  good  light  is  essential. 

The  inferior  thyroid  veins  may  prove  very  troublesome. 

The  sheath  is  opened  on  its  inner  side,  as  already  described, 
and  the  needle  is  jjassed  from  without  inwards. 

GoTrument. —  The  observations  made  upon  the  previous 
measure  apply  in  the  main  to  the  present  proceeding. 

The  depth  at  which  the  vessel  is  placed  renders  the 
operation  difficult  and  dangerous,  and  on  the  left  side  the 
surgeon's  movements  are  apt  to  be  complicated  by  the 
position  of  the  internal  jugular  vein. 

The  relations  of  the  inferior  thyroid  artery,  and  of  the 
recurrent  laryngeal  nerve,  must  be  borne  in  mind. 

Collateral  Circulation  after  Ligature  of  the  Common 
Carotid. 

Cardiac  Side.  Distal  Side. 

Inferior  thyroid  with  Superior  thjToid. 

Deep  cervical  with  Occipital. 

Transversalis  colli  with  Occipital. 

The  communications  between  the  two  vertebral  aiteries  and  the  branches  of 
the  two  external  carotid  arteiies. 

The  communications  effected  by  the  circle  of  "Willis. 

Varieties  of  the  Common  Carotid  Artery. 

1.   Variations  in  the  origin  of  tlie  vessels  have  little 
effect  upon  their  course  in  the  neck. 


156  OPERATIVE    SURGERY. 

2.  The  innominate   may  bifurcate  higher  (as  a  rule, 

lower)  than  usual. 

3.  The  artery  may  bifurcate  as  high  up  as  the  level 

of  the  hyoid  bone,  or  as  low  as  the  level  of  the 
middle  of  the  larjrtix,  or  even  of  the  cricoid 
cartilage. 

4.  The  place  of  the  common  carotid  may  be  taken 

by  two  parallel  vessels — the  external  and  internal 

carotids. 
6.  From  the  upper  part   of  the   artery  the   superior 

thyroid,  or  ascending  pharyngeal  artery,  may  arise. 
6.  The   vagus   nerve   has   descended   in  front  of  the 

artery. 

THE  EXTERNAL  CAROTID  ARTERY  (ll.). 

Anatomy. — This  artery  extends  from  the  level  of  the 
upper  border  of  the  thyroid  cartilage  to  the  level  of  the  neck 
of  the  inferior  maxilla.  It  is  somewhat  tortuous,  but  when 
rendered  straight  measures  about  two  and  three-quarter 
inches.     It  diminishes  rapidly  in  size  as  it  ascends. 

About  its  origin  it  is  covered  only  by  the  integuments,  the 
platysma,  and  the  cervical  fascia,  and  at  the  same  part  it 
is  overlapped  by  the  sterno-mastoid  muscle.  It  soon  becomes 
deeply  placed,  and  passes  beneath  the  digastric  and  stylo- 
hyoid muscles,  and  ultimately  through  a  portion  of  the 
parotid  gland.  In  its  upper  part,  it  is  separated  from  the 
internal  carotid  by  the  styloid  process,  the  stylo-pharyngeus 
muscle,  and  the  glosso-pharyngeal  nerve. 

At  the  lower  edge  of  the  digastric  muscle  the  hypoglossal 
nerve  crosses  in  front  of  the  artery.  Below  this  nerve  the 
facial  and  hngual  veins  cross  the  vessel  on  its  anterior  asj)ect. 
Some  way  above  the  digastric  the  glosso-pharyngeal  nerve 
passes  obliquely  behind  the  external  carotid.  The  infra- 
maxiUary  branches  of  the  facial  nerve  are  superficial  to 
the  artery  above  the  digastric.  The  superior  laryngeal  nerve 
is  placed  obHquely  behind  the  vessel  near  its  origin. 

The  anterior  division  of  the  temporo-maxOlary  vein  may 
pass  with  the  artery  beneath  the  digastric  muscle.  More 
usually  it  lies  superficial  to  that  vessel 

The  superior  thyroid  arises  directly  from  the  artery  at  its 


LIGATURE    OF   EXTERNAL    CAROTID    ARTERY.      157 

commencement.  The  lingual  takes  origin  at  a  level  with  the 
greater  cornu  of  the  hyoid  bone.  The  facial  and  occipital 
arise  at  the  same  level  a  httle  above  the  lingual. 


Neck  of  condyle  of 
lower  jaw. 


Great     comu     of 
hyoid  bone. 


Upper    margin   of 
thyroid  cartilage. 


Fig.  40. — EXTERNAL  OABOTID  ARTERY,  NATURAL  SIZE.    {Modified  from  Quain.) 
A,  Site  of  ligature  ;  D,  Digastric  muscle. 


Fig.  40  shows  the  artery  at  about  its  natural  size,  and 
serves  to  indicate  the  dimensions  and  position  of  the  branches 
of  the  trunk,  the  intervals  which  separate  their  points  of  origin, 
and  the  relations  of  one  branch  to  another.  The  more  im- 
portant landmarks  in  the  course  of  the  artery  are  also  shown. 

It  will  be  observed  that  the  digastric  muscle  crosses  the 


158  OPERATIVE    SURGERY. 

artery  about  one  inch  and  a  quarter  above  its  origin  from 
the  common  carotid,  and  that  the  hypoglossal  nerve  crosses 
at  about  the  height  of  one  inch. 

The  segment  between  the  bifurcation  and  the  digastric 
muscle  represents  the  most  superficial  and  most  accessible 
part  of  the  artery. 

Line  of  the  Artery. — The  external  carotid  is  represented 
by  the  upper  part  of  the  common  carotid  line. 

Others  have  proposed  a  line  drawn  from  the  tip  of  the 
lobule  of  the  ear  to  the  tip  of  the  gi-eater  cornu  of  the  hyoid 
bone. 

Indications. — The  artery  has  been  ligatured  for  hi3emor- 
rhage  following  wounds  and  injuries,  and  involving  the  trunk 
or  the  branches  of  the  vessel,  for  the  cure  of  aneurysm  and 
the  relief  of  cirsoid  aneurysm  of  the  scalp.  It  has  been 
ligatured  as  a  palliative  measure  in  the  case  of  certain 
mahgnant  growths,  and  has  been  secured  as  a  preliminary 
measure  to  certain  operations,  e.g.,  removal  of  the  maxilla, 
excision  of  parotid  tumour,  and  the  like.  Harrison  Cripps 
(Med.-CJtir.  Trans.,  vol.  Ixi.,  page  234)  very  properly  urges  that 
in  all  cases  of  haemorrhage  from  branches  of  the  external 
carotid  that  vessel  should  be  secured  whenever  possible,  in 
place  of  the  common  carotid.  The  operation  is  certainly 
less  easy,  but  it  is  attended  with  an  infinitely  smaller  mort- 
ahty,  the  risks  of  secondary  bleeding  are  reduced,  and  the 
brain  complications,  which  are  so  frequent  a  cause  of  death 
after  hgature  of  the  common  trunk,  are  avoided. 

Among  the  first  to  ligature  the  external  carotid  Chelius 
names  Bushe,  1827  {Lancet,  1827-8,  page  482),  who  applied  a 
hgature  on  account  of  cirsoid  aneurysm,  and  Lizars,  1829 
{Lancet,  1829-30,  page  54),  as  preliminary  to  removal  of  the 
upper  jaw. 

Operation. — The  position  of  the  patient  and  of  the  opera- 
tor should  be  the  same  as  is  observed  in  the  previous  opera- 
tion. 

The  "  place  of  election "  is  represented  by  the  portion 
of  the  vessel  between  the  superior  thyroid  and  lingual  arteries. 

An  incision,  two  and  a  half  to  three  inches  in  length, 
is  made  in  the  line  of  the  artery  from  a  point  about  on  a  level 
with  the  middle  of  the  thyroid  cartilage  to  near  the  angle  of 


LIGATURE    OF   EXTERNAL    CAROTID    ARTERY.      150 

the  jaw.     The  greater  cornu  of  the  hyoid  bone  will  be  about 
the  centre  of  the  incision. 

The  integiunents  and  platysma  having  been  divided,  and 
any  superficial  vein  secured,  the  fascia  is  cut  through,  and  the 
anterior  border  of  the  sterno-mastoid  is  exposed  in  the  lower 
part  of  the  wound.  This  muscle  must  be  drawn  outwards. 
The  posterior  belly  of  the  digastric  should  next  be  sought  for 
at  the  upper  angle  of  the  wound,  and  below  it  the  hypoglossal 
nerve  should  bo  made  evident.  The  surgeon  now  seeks  Avith 
the  linger  for  the  tip  of  the  great  cornu  of  the  hyoid  bone,  and 
when  this  is  discovered  all  the 
"points"  leading  to  the  artery 
are  in  evidence  (Fig.  41).  A 

The    artery   should    now  be         A -  /jp!^ 

exposed  opposite  to  the  level  of  :;  L^^^^  j. 

the    tip     of    the    great    cornu,       ^  4j^^^^v\v 

and  between  the  origins  of  the  l^SBI^m 

superior    thyroid     and    lingual    ^     _   il^^^Mw^ 
arteries.     In    this    part    of    the    ''         iflHD  |y^'      ■-"-  -"^ 
operation  care  must  be  taken  to  (Iw^^BuBI 

avoid   the   facial    and    superior        " V:ip^^^^fctr— - — s; 

thyroid       veins.  Lymphatic      c -■'■■^Ww^B^' l  '^ 

glands   may  he  in  front  of  the  V Wli^    i 

vessel.     The  artery  having  been  '^o*^*^     ■   I'-  " 

cleared,   the    needle    is    passed  \^-->y 

from  without  inwards.     In  effect-  ^^f 

ing    this,    great    care    must  be  W 

taken    to    avoid     the     superioi- 

laryngeal  nerve,  which   courses     ^'^-  ^^•""JfircAROTiD^"'"''  ^''' 

behind  the   artery    m    this    situa-       a,  Platysma  ;    b,   Cervical  fascia  ;  c, 
i-j^j^  sterno-mastoid  ;    I),    Digastric  ;    K, 

Great  cornu  of  hyoid  bone  ;  a,  Ex- 

Jacobson     advises      that      the  temal  carotid  at  origin  of  superior 

.1  •  T  IT  1  thyroid;  6,  Crossing  lingual  artery 

superior       thyroid      and      ImgUal,  points    to   lingual    vein:    r,    Facial 

and,      if     pOS^sible,      the      ascend-  artery ;  rf,  Facial  and  superior  thy- 

'  i  '  _  roid  veins  ;  1,  Hypoglossal  nerve. 

ing   phar}rQgeal   arteries,  should 

be  secured  at  the  same  time,  to  minimise  the  risk  of  secondary 

hiemorrhage. 

Comment. — This  operation  is  somewhat  difficult,  on  ac- 
count of  the  complicated  relations  of  the  arteiy,  and  the  fact 
that  the  branches  are  not  always  readily  identitied. 


160  OPERATIVE    SURGERY. 

The  artery  has  been  hgatured  above  the  digastric ;  but  the 
procedure  is  still  more  difficult,  and  is  attended  with  several 
special  risks.  The  operation  "behind  the  ramus  of  the  jaw" 
is  thus  described  by  Jacobson  : — "  This  operation  has  the 
disadvantage  of  probably  entailing  the  division  of  important 
branches  of  the  facial  nerve.  The  head  and  shoulders  being 
duly  raised  and  supported,  the  surgeon  makes  an  incision 
downwards  from  the  tragus  of  the  ear,  just  behind  the  ramus 
of  the  jaw,  dividmg  the  skin  and  fasciae.  The  sterno-mastoid 
must  now  be  drawn  outwards,  and  the  digastric  and  stylo- 
hyoid downwards,  and  it  will  probably  be  needful  to  divide 
these  muscles  partially,  in  order  to  secure  the  artery  before  it 
enters  the  parotid  gland,  this  structure  being  drawn  upwards 
and  forwards.  The  needle  may  be  passed  from  either  side,  as 
is  most  convenient  to  the  surgeon. 

"  Several  veins  communicating  between  the  facial  and  the 
external  jugular  will  probably  cross  the  line  of  incision,  and 
must  be  dealt  with." 

Collateral  Circulation  after  Ligature  of  the  External 
Carotid. — {See  the  collateral  circulation  after  ligature  of  the 
common  carotid.) 

Varieties  of  the  External  Carotid. 

1.  See  the  varieties  of  the  common  carotid. 

2.  The  branches  of  the  artery  may  be  crowded  together 

near  the  commencement  of  the  trunk. 

3.  The  number  of  branches  may  be  diminished ;  two  or 

three  arising  from  one  trunk. 

4.  The  number   of  branches  may  be   increased ;   sub- 

sidiary vessels  arising  from  the  main  artery. 

THE  INTERNAL   CAROTID   ARTERY   (ll.). 

Anatomy, — In  its  course  in  the  neck  this  artery  extends 
from  the  bifurcation  to  the  carotid  canal  in  the  petrous  bone. 
The  vessel  lies  at  first  a  little  behind  the  external  carotid,  and 
sUghtly  to  its  outer  side. 

The  first  part  of  the  vessel  is  comparatively  superficial^ 
and  is  the  only  portion  to  which  a  ligature  can  conveniently 
be  applied.  This  portion,  which  is  not  more  than  one  inch 
itnd  a  quarter  in  length,  is  covered  by  the  integuments, 
platysma  and  deep  fascia,  and  is  overlaj)ped  by  the  sterno- 


LIGATURE    OF   INTERNAL    CAROTID    ARTERY.      161 

mastoid.  The  artery  soon  becomes  more  deeply  placed  by 
passing  beneath  the  digastric,  stylo-hyoid,  and  stylo-pharyn- 
geus  muscles.,  and  with  this  segment  we  have  no  concern. 
The  internal  jugular  vein  is  close  to  the  artery,  lying  to  its 
outer  side  below,  and  a  httle  to  the  postero-extemal  aspect  as 
the  skull  is  reached.  The  vessel  hes  upon  the  spine  and 
rectus  capitis  anticus  major,  and  is  in  close  relation  with  the 
pharynx.  It  is  invested  in  a  sheath,  which  encloses  also  the 
vein  and  the  vagus  nerve,  the  latter  structure  being  posterior 
to  both  the  vessels. 

The  superior  cervical  ganglion  Hes  behind  the  commence- 
ment of  the  artery  (corresponding  to  thefirst  three  cervical  verte- 
bne),  and  is  separated  from  it  by  the  superior  laryngeal  nerve. 

The  Line  of  the  Artery  is  practically  identical  with  that 
for  the  external  carotid. 

Indications. — This  vessel  has  been  but  very  rarely  liga- 
tured. It  has  been  secured  in  cases  of  hsemorrhage  following 
injury,  and  notably  j^unctured  wounds,  and  also  in  cases  of 
traumatic  aneurysm. 

The  internal  carotid  was  hgatured  by  Keith,  of  Aberdeen, 
in  1851  (Ashhurst's  "Encyclopaedia  of  Surgery,"  voL  iii., 
page  294). 

Dr.  Lee,  of  Kingston,  United  States,  secured  the  artery  by 
two  ligatures,  in  a  case  of  stab  of  the  neck,  in  1869.  The 
patient  recovered  (ibid.). 

Dr.  Briggs,  of  Nashville,  United  States,  tied  the  artery  on 
the  distal  and  proximal  side  of  a  traumatic  aneurysm  with 
success,  in  1871.  He  hgatured  the  common  carotid  at  the 
same  time  {Amer.  Journ.  of  the  Med.  Sc,  Jan.,  1879),  and  in 
1874  Dr.  Sands,  of  New  York,  secured  the  artery  above  and 
below  the  bleeding  point,  in  a  case  of  secondary  haemorrhage, 
following  an  operation  for  the  removal  of  the  lower  jaw.  The 
case  was  successful  {New  York  Med.  Journ.,  Jan.,  1874). 

Operation. — The  position  of  the  patient  and  the  surgeon 
is  the  same  as  is  observed  in  the  operations  upon  the  common 
or  external  carotid. 

The  internal  carotid  is  secured  only  at  its  commencement, 
close  to  the  bifurcation,  and  the  operation  is,  in  all  essential 
features,  identical  with  that  employed  in  hgaturing  the 
external  carotid  at  the  place  of  election. 


162  OPERATIVE    SURGERY. 

The  incision  is  of  tlie  same  length,  and  occupies  the  same 
position  in  the  neck,  so  far  as  the  vertical  line  is  concerned. 
It  is  placed  over  the  anterior  edge  of  the  sterno-mastoid  (with 
which  it  is  parallel),  and  is  therefore  a  little  external  to  the 
incision  required  for  the  external  carotid. 

The  muscle  is  drawn  outwards.  The  external  carotid  is 
sought  for  and  exposed,  and  then  the  operator  brings  into 
view  the  internal  trunk.  The  former  vessel  is  drawn  inwards 
with  a  small  blunt  hook,  the  latter  outwards.  The  digastric 
muscle  is  drawn  upwards. 

The  sheath  of  the  vessels  is  opened  with  care,  and  directly 
over  the  artery.  The  needle  is  passed  from  without  inwards, 
with  the  same  precautions  as  are  observed  in  Hgaturing  the 
common  carotid.  Care  must  be  taken  to  avoid  injury  to  the 
internal  jugular  vein,  the  vagus  nerve,  the  sympathetic 
ganghon,  and  the  ascending  pharyngeal  artery,  all  of  which 
are  very  close  to  the  vessel  at  the  seat  of  ligature. 

Collateral  Circulation  after  Ligature  of  the  Internal 
Carotid. — The  circulation  between  the  two  internal  carotids 
and  the  vertebrals  is  exceedingly  free  through  the  circle  of 
Wilhs. 

Varieties  of  the  Internal  Carotid  Artery. 

1.  The  cervical  part  may  be  unduly  tortuous. 

2.  The  artery  has,  in  rare  cases,  been  absent. 

3.  It  has  given  off,  from  its  lower  part,  the  occipital 

or  the  ascending  pharyngeal  arteries. 

THE   SUPERIOR   THYROID   ARTERY   (iV.). 

Anatomy. — This  vessel  is  the  first  branch  of  the  external 
carotid,  and  arises  close  to  the  bifurcation,  and  a  little  way 
below  the  greater  cornu  of  the  hyoid  bone.  It  curves,  at  first,  a- 
Uttle  upwards,  and  then  runs  downwards  and  forwards  (Fig.  40). 

It  is  only  superficial  at  its  commencement.  It  is  in  close 
relation  behind  with  the  superior  laryngeal  nerve.  Its  first 
branch  is  the  hyoid,  and  its  second — which  is  close  to  it — is 
the  sterno-mastoid.  The  former,  as  a  rule,  arises  about 
a  quarter  of  an  inch  from  the  point  of  origin  of  the  superior 
thyi'oid.  A  more  considerable  interval  intervenes  between  the 
sterno-mastoid  artery  and  the  next  branch,  the  superior 
aryngeaL  . 


LIGATURE    OF   LINGUAL    ARTERY.  163 

The  ligature  is  most  conveniently  applied  between  these 
two  branches. 

The  superior  thyroid  artery  varies  much  in  size.  There 
may  be  two  vessels,  or  a  single  trunk  may  arise  from  the 
common  carotid  or  lingual  arteries. 

Operation. — The  operation  is  in  all  essential  particulars 
identical  with  that  employed  in  exposing  the  external  carotid 
at  the  place  of  election  (Fig.  41). 

The  incision  is  about  two  inches  in  length,  and  is  so  placed 
along  the  carotid  line  that  the  centre  of  the  cut  is  on  a  level 
with  the  upper  margin  of  the  thyroid  cartilage.  The  external 
carotid  should  be  made  evident,  and  the  superior  thyroid 
traced  from  it.  The  ligature  may  be  apphed  close  to  the 
external  carotid,  between  it  and  the  hyoid  branch,  or,  prefer- 
ably, nearer  to  the  larynx,  and  beyond  the  origin  of  the 
sterno-mastoid  artery. 

The  superior  thyroid  veins,  which  often  have  a  plexiform 
arrangement,  may  complicate  the  ojDeration.  The  needle  may 
be  passed  from  above  downwards.  Care  must  be  taken  to 
avoid  the  superior  laryngeal  nerve. 

THE    LINGUAL    ARTERY    (iV.). 

Anatomy. — This  artery  arises  nearly  opposite  to  the  greater 
cornu  of  the  hyoid  bone,  and  about  three-quarters  of  an  inch 
above  the  bifurcation  of  the  carotid.  It  ascends  a  little,  and 
then,  passing  downwards  and  forwards,  forms  a  curve  (Fig. 
40).  It  soon  disappears  beneath  the  digastric  and  stylo-hyoicl 
muscles,  and  running  forwards  under  the  hyo-glossus,  and 
along  the  upper  border  of  the  greater  cornu  of  the  hyoid  bone, 
it  reaches  the  anterior  margin  of  that  nmscle,  where  it  turns 
upwards  to  enter  the  under  surface  of  the  tongue. 

The  first  2^cc7i  of  the  vessel  extends  from  its  origin  to  the 
posterior  margin  of  the  hyo-glossus  muscle  (kerato-glossus). 

The  second  part  is  that  which  lies  under  the  hyo-glossus 
muscle;  and  the  third  part  is  that  slender  portion  of  the 
vessel  which  extends  beyond  the  anterior  margin  of  the 
muscle  (basio-glossus). 

Th.Q  first  part  is  covered  by  the  skin,  platysma,  and  deep 
fascia,  and  by  some  of  the  cervical  glands.  It  forms  a  kind 
of  loop,  Avhich  is  crossed  by  the  hypoglossal  nerve,  and  by 
L  2 


164  OPERATIVE    SURGERY. 

the  facial  and  lingual  veins.  The  digastric  and  stylo-hyoid 
muscles  cross  this  segment  of  the  artery  before  the  hinder 
border  of  the  hyo-giossus  is  reached. 

This  part  of  the  lingual  hes  behind,  upon  the  middle  con- 
strictor and  the  superior  laryngeal  nerve. 

From  the  first  part  arise  the  hyoid  and  dorsalis  hnguai 
branches,  the  former  about  half  an  inch  from  the  orisin  of 
the  artery,  the  latter  near  to  the  posterior  border  of  the  hj'^o- 
giossus,  under  cover  of  which  border  it  ascends  to  the  tongue. 

The  hyoid  branch  is  inconstant,  and  may  be  absent. 

The  second  part  of  the  lingual  lies  beneath  the  hyo-glossus, 
and  has  a  nearly  horizontal  course.  It  rests  upon  the  genio- 
glossus,  and  is  placed  below  the  level  of  the  hypoglossal 
nerve,  which  is  entirely  superficial  to  it.  The  sublingual 
branches  arise  from  this  part,  taking  origin  near  the  anterior 
border  of  the  hyo-glossiis  muscle. 

The  third  part  of  the  artery  takes  the  name  of  the  ranine, 
and  is  distributed  to  the  tongue. 

The  veins  attending  the  lingual  artery  are  divided  into 
three  sets.  1.  The  ranine  vein,  the  largest,  has  a  course 
independent  of  the  artery.  It  runs  on  the  superficial  surface 
of  the  hyo-glossus,  below  the  hypoglossal  nerve,  and  about 
on  a  level  with  the  lingual  artery,  which  is  beneath  the 
muscle.  2.  Two  very  small  venaB  comites  accompany  the 
artery  in  its  course  beneath  the  hyo-glossus.  3.  Several  veins 
usually  attend  the  dorsahs  hnguse  artery,  and  often  have  a 
plexiform  arrangement.  These  three  sets  of  veins  may  enter 
into  a  common  trunk,  the  lingual  vein,  but  very  frequently 
they  enter  separately  into  the  internal  jugular,  or  common 
facial  veins. 

The  Ungual  artery  may  arise  from  the  superior  thyroid,  or 
from  the  facial,  or  it  may  be  replaced  by  a  branch  of  the 
internal  maxiUary  artery. 

The  vessel  may  run  between  the  fibres  of  the  hyo-glossus 
muscle,  close  to  its  origin  from  the  bone. 

Indications. — The  lingual  has  been  hgatured  in  cases  of 
hemorrhage  following  wound  of  the  artery  or  its  branches. 
The  hgature  has  been  employed  to  arrest  bleeding  in  advanced 
cancer  of  the  tongue,  and  to  modify  the  growth  of  the  cancer 
in  cases  unfitted  for  other  operation.     The  lingual  has  been 


LIGATURE    OF    LINGUAL    ARTERY.  165 

secured  in  the  treatment  of  macroglossa.  The  most  common 
circumstance,  however,  under  which  this  vessel  is  tied,  is  as  a 
preUminary  measure  in  the  removal  of  the  tongue. 

The  artery  may  be  secured  in  either  the  first  or  the  second 
part  of  its  course.  In  the  former  situation  a  ligature  is  but 
very  rarely  apphed,  the  place  of  election  being  in  the  second 
segment  of  the  vessel  as  it  lies  beneath  the  hyo-glossus  muscle, 
and  occupies  the  digastric  triangle. 

The  operation  for  the  ligature  of  the  first  part  is  ascribed 
to  Charles  Bell  (1814),  and  that  for  the  securing  of  the  lingual 
at  the  place  of  election  to  Pirogofif  (1836). 

1.  Ligature  of  the  Artery  at  the  "  Place  of  Election," 
i.e.,  beneath  the  hyo-glossu.s  'tnusde. 

Position. — The  patient  lies  close  to  the  edge  of  the  table, 
with  the  shoulders  raised,  with  the  arm  of  the  affected  side 
passed  behind  the  back,  and  with  the  face  turned  to  the  oppo- 
site side.  An  assistant  must  keep  the  chin  drawn  well  up- 
wards, and  the  lower  jaw  fixed.  The  surgeon  stands  upon 
the  side  to  b©  operated  upon.  The  chief  assistant  is  placed 
opposite  to  him,  and  leans  over  the  patient's  body.  A  second 
assistant  stands  by  the  surgeon's  side.  His  chief  duty  is  to 
hold  the  hook  which  commands  the  digastric  tendon.  The 
patient  must  be  well  anaesthetised  before  the  operation  is 
commenced.  In  male  subjects  the  skin  of  the  submaxillary 
region  should  be  shaved. 

Operation. — An  incision,  some  two  inches  in  length, 
curved,  and  with  the  convexity  downwards,  is  made  between 
the  lower  jaw  and  the  hyoid  bone.  The  wound  commences  a 
Uttle  below  and  to  the  outer  side  of  the  symphysis,  and  ends 
a  httle  below  and  to  the  inner  side  of  the  point  where  the 
facial  artery  crosses  the  lower  margin  of  the  maxilla.  Its 
centre  is  just  above  the  greater  cornu  of  the  hyoid  bone  (Fig. 
36).  On  the  right  side  the  incision  is  made  from  behind  for- 
wards, on  the  left  side  from  before  backwards. 

The  integuments,  platysma,  and  superficial  fascia  are  di- 
vided in  the  line  of  the  incision.  Certain  superficial  veins 
will  be  encomitered,  and  some  wiU  probably  have  to  be 
secured.  These  veins  are  the  submental  or  other  tributary  of 
the  facial,  or  some  tributary  of  the  anterior  jugular. 

It  will  now  be  convenient  to  apply  hgature  retractors  {see 


166  OPERATIVE    SUliGEBY. 

pag-e  55)  in  order  that  the  depths  of  the  wound  might  be  well 
laid  open. 

The  next  step  is  to  fully  expose  the  submaxillary  gland. 
It  is  lodged  in  a  special  compartment  of  the  cervical  fascia. 
Tills  fascia  should  be  opened  transversely  over  the  lower  part 
of  the  gland,  and  the  organ  should  be  cleared  and  brought 
well  out  into  the  wound  by  means  of  the  finger  and  the 
handle  of  a  scalpel.  The  gland  should  be  turned  upwards  on 
to  the  margin  of  the  jaw,  and  be  kept  out  of  the  operation 
area  by  means  of  a  broad  and  well-curved  retractor  held  by 
the  chief  assistant. 

The  fascia  exposed  by  the  lifting  out  of  the  salivary  gland 
is  now  to  be  divided  transversely,  and  in  the  anterior  angle  of 
the  wound  the  posterior  edge  of  the  mylo-hyoid  muscle  must 
be  sought  for  and  defined. 

The  digastric  tendon  and  the  two  bellies  of  the  muscle  are 
now  to  be  brought  clearly  into  view.  Around  the  tendon, 
where  it  is  nearest  to  the  hyoid  bone,  a  small  blunt  hook  with 
a  very  long  shaft  or  handle  is  to  be  passed  and  held  by  the 
assistant  who  stands  at  the  surgeon's  side.  The  tendon  should 
be  drawn  downwards  and  towards  the  surface. 

By  this  means  the  area  of  the  operation  is  brought  well 
mto  view,  and  is  increased  in  extent ;  the  parts  are  fixed ;  the 
hyoid  bone,  carrying  with  it  the  hyo-glossus  muscle,  is  brought 
nearer  to  the  surface,  and  the  muscle  in  question  is  put  upon 
the  stretch. 

The  hyo-glossus  muscle  can  be  now  easily  made  out,  and 
its  exposed  surface  freed  of  connective  tissue.  The  hypo- 
glossal nerve  must  be  sought  for,  as  it  crosses  the  muscle,  and 
the  surgeon's  work  be  limited  to  the  segment  of  muscle  below 
the  nei-ve  (Fig.  42). 

Crossing  the  hyo-glossus  beloAv  the  nerve,  and  parallel  with 
It,  is  the  ranine  vein.  This  vein  will  about  correspond  in 
position  with  the  artery,  which  hes  beneath  the  muscle. 

The  vein  and  the  nerve  should  be  displaced  upwards. 

The  hyo-glossus  muscle  is  divided  transversely  to  the 
extent  of  about  half  an  inch,  a  Uttle  above  the  margin  of  the 
hyoid  bone,  and  parallel  with  it. 

The  incision  in  the  muscular  tissue  must  be  cautiously 
deepened.     If  the  cut  has  been  Avell  placed,  the  artery  will 


LIGATURE    OF    LINGUAL    ARTERY. 


lt)7 


bend  out  into  the  wound  and  make  itself  evident  as  soon  as 
the  whole  thickness  of  the  muscle  has  been  divided. 

The  needle— unthreaded — is  most  conveniently  passed 
from  above  downwards.  In  the  ligature  the  minute  venie 
comites  which  attend  the  artery  are  no  doubt  included. 

The  wound  is  gently  washed  out,  and  the  gland  replaced. 
The  edges  of  the  inci- 
sion are    adjusted    by 
sutures,  but  no  drain- 
age-tube is  required. 

Comment.  —  This 
operation  requires  a 
good  light,  and  is  only 
performed  with  ease 
and  certainty  when  the 
procedure  is  carried  out 
step  by  step. 

The  stages  of  the 
operation  should  be 
marked  in  succession 
by  the  following  points: 
1.  The  com^^lete  lifting 
up  of  the  submaxillary 
gland.  2.  The  demon- 
stration of  the  edge  of 
the  mylo-hyoid  muscle. 

3.  The  clearing  of  the 
digastric  tendon,  and  the  drawing  of  it  outwards  Avith  a  hook. 

4.  The  demonstration  of  the  hypoglossal  nerve  on  the  hj-o- 
glossus  muscle. 

The  incision  may  be  of  less  dimensions  than  those  given, 
or  may  be  extended  if  required. 

If  the  cut  be  carried  too  far  back,  the  facial  vein  and  artery 
are  endangered.  Time  should  not  be  wasted  over  the  early 
part  of  the  operation.  Such  veins  as  are  cut  may  be  clamped 
and  left.  They  seldom  require  a  ligature.  The  gland  must 
be  well  exposed.  The  chief  difficulties  of  the  operation 
depend  upon  the  gland.  I  have  hgatured  the  lingual  more 
than  sixty  times  (all  in  cases  of  carcinoma  of  the  tongue),  and 
have  come  to  regard  the  state  of  the  saHvary  gland  as  the 


Fig.    42. — IIGATUEE    OF   EIGHT  LINOTTAL   ARTERY 

A,  Platysma  ;  b,  Cervical  fascia  ;  c,  Submaxillary 
gland  ;  D,  Mylo-hyoid  ;  E,  Digastric ;  F,  Hyo- 
glossus  ;  a,  Lingual  artery  ;  b,  Ranine  vein  ;  1, 
Hypoglossal  nerve. 


lt)8  OPERATIVE    SURGERY. 

main  element  of  uncertainty  in  the  procedure.  Tliis  gland 
varies  in  size,  in  density,  and  in  the  closeness  of  its  attach- 
ments. These  variations  are  probably  never  normal,  but  are 
incident  to  changes  connected  with  cancer  of  the  tongue. 

It  is  most  important  that  the  gland  be  neither  wounded 
nor  damaged,  as  a  temporary  saHvary  fistula  may  possibly 
follow. 

As  soon  as  the  gland  has  been  turned  out  of  its  bed,  steps 
must  be  taken  to  keep  the  wound  quite  bloodless.  Other 
comphcations  are  afforded  by  a  matting  together  of  parts  by  a 
past  inflammation,  by  the  presence  of  unusual  veins,  or  of 
enlarged  lymphatic  glands. 

As  the  wound  becomes  deep,  and  the  area  of  the  operation 
very  narrow,  a  pair  of  long-bladed  and  fine  dissecting  forceps 
is  needed. 

The  fixing  of  the  digastric  tendon  and  the  hyoid  bone  by 
means  of  the  small  hook  is  an  essential  part  of  the  operation. 
Embarrassed  breathing  may  form  a  serious  complication  in 
the  later  stages  of  the  procedure. 

The  hyo-glossus  muscle  varies  in  thickness;  the  part 
divided  is,  in  the  main,  the  basio-glossus,  and  the  beginner 
will  find  the  muscle  much  thicker,  probably,  than  he  had 
imagined. 

The  lingual  has  been  cut  in  dividing  the  muscle  carelessly. 
The  bulging  of  the  artery  uito  the  wound  in  the  muscle  is 
very  characteristic  whenever  the  incision  has  been  fortunate 
enough  to  be  accurately  placed.  I  know  of  no  artery  Avhich, 
when  exposed  by  operation,  looks  less  hke  an  artery  than  the 
lingual. 

2.  Ligature  of  the  Artery  at  its  First  Part. 

Operation. — The  patient's  position  is  the  same  as  is  ob- 
served in  Hgature  of  the  external  carotid. 

The  same  incision  may  be  used  as  is  employed  in  securing 
that  artery.  The  cut,  however,  should  be  shorter,  and  be  so 
placed  that  its  centre  is  opposite  to  the  body  of  the  hyoid  bone. 

After  the  superficial  structures  have  been  divided,  the 
external  carotid  should  be  sought  for,  and  followed  until  the 
lingual  is  reached  (Fig.  41). 

Or  an  incision  about  one  inch  and  a  half  long  may 
be    made    traiisvoi  sely  in   the  neck,   just  over   the    greater 


LIGATURE    OF   FACIAL   ARTERY.  169 

cornu  of  the  hyoid  bone.  This  cut  should  be  slightly  convex 
downwards,  and  should  extend  from  the  level  of  the  body  of 
the  hyoid  bone  to  the  margin  of  the  stemo-mastoid  muscle. 
The  integuments,  platysma,  and  fascia  having  been  divided, 
the  greater  comu  of  the  hyoid  bone  is  sought  for.  The  sub- 
maxillary gland  is  displaced  upwards.  The  hypoglossal 
nerve  is  demonstrated,  and  the  artery  exposed  just  at  the 
anterior  border  of  the  hyo-glossus  muscle,  and  secured  before 
it  has  passed  beneath  that  structure. 

Comment. — These  operations  are  dangerous  and  difficult. 
The  Hgature  is  applied  to  the  trunk  on  the  proximal  side  of 
the  dorsalis  lingune,  but  this  advantage  is  of  no  great  value,  as 
I  am  not  aware  that  any  difficulty  has  arisen  from  leaving  the 
dorsaUs  linguse  unsecured.  The  situation  has  many  disad- 
vantages. The  origin  of  the  lingual  is  subject  to  variation. 
Tlie  ligature  is  applied  close  to  the  main  artery.  The  wound 
is  deep,  and  the  artery  is  not  supported  upon  any  resisting 
structure.  Numerous  veins,  moreover,  more  or  less  entirely 
obscure  the  tirst  portion  of  the  vessel. 

LIGATURE   OF    OTHER   BRANCHE.S   OF   THE   EXTERNAL   CAROTID. 

The  facial,  temporal,  or  occipital  arteries  may  require  to 
be  Hgatured  in  cases  of  wound,  and  in  still  rarer  instances 
of  traumatic  aneurysm.  The  two  latter  vessels  have  also  been 
secured  in  the  treatment  of  cirsoid  aneurysm  of  the  scalp. 

It  is  unnecessary  to  detail  in  precise  manner  the  various 
steps  involved  in  the  securing  of  these  and  other  of  the 
smaller  arteries  of  the  head  and  neck. 

In  most  instances  the  operation  is  informal,  and  consists 
merely  in  picking  up  a  bleeding  vessel  at  the  bottom  of  an 
existing  wound,  which,  at  the  most,  has  been  merely  enlarged. 

The  Facial  Artery  (IV.)  has  been  ligatured  in  the  neck, 
through  an  incision  similar  to  that  employed  in  exposing  the 
external  carotid  artery,  or  the  commencement  of  the  lingual 
(Fig.  41).  It  is,  however,  most  conveniently  secured  as  it 
crosses  the  lower  margin  of  the  jaw  (Fig.  43).  A  horizontal 
incision,  one  inch  in  length,  is  made  across  the  course  of  the 
vessel,  along,  and  under  cover  of,  the  inferior  margin  of  the 
jaw.  The  artery  crosses  this  margin  at  the  anterior  border 
of  the  masseter  muscle.     After  the  skin,  platysma,  and  fascia 


17U 


OPERATIVE    SURGERY. 


liave  been  divided,  the  arteiy  should  be  in  evidence,  especially 
as  its  pulsations  are  readily  felt.  The  facial  vein  is  behind 
the  artery,  and  very  close  to  it.  The  needle  should  be  passed 
from  behind  forwards. 

A  vertical  incision  in  the  course  of  the  artery  has  been 


Fig.    43.— DIAGEAM  TO  SHOW  THE  POSITION  OF  THE  FACIAL,   TEMPORAL,   AND 

OCCIPITAL  AETEEiES.     (Modified  fro/H  Merkel.) 


advised ;    but  it  exposes   the  vessel    in   a   less    convenient 
manner,  and  leaves  a  more  conspicuous  scar. 

The  Temporal  Artery  (IV.)  may  be  secured  just  in  front 
of  the  meatus,  as  the  vessel  leaves  the  j)arotid  gland.  An 
incision  one  inch  in  length  is  made  vertically,  over  the  course 
of  the  vessel,  between  the  tragus  and  the  condyle  of  the  jaw. 
The  artery  is  ligatured  just  above  the  root  of  the  zygoma  (Fig. 
43).     It  is  here  covered  by  the  skin  and  a  dense  fascia.     A 


LIGATURE    OF    OCCIPITAL    ARTERY.  171 

single  lai-o-c  vein  accompanies  it,  lying  behind  the  artery  and 
overlapping  it.  The  vessel  is  crossed  by  branches  of  the  tem- 
poro-facial  division  of  the  facial  nerve,  and  lies  over  and  behind 
the  aiiriculo-temporal  nerve.  The  needle  is  passed  from 
behind  forwards. 

The  temporal  bifurcates  about  one  inch  and  a  quarter 
above  the  root  of  the  zygoma. 

The  Occipital  Artery  (IV.)  has  been  ligatured  close  to  its 
origin,  and  also  in  that  part  of  its  course  which  lies  beyond 
the  mastoid  process  (Fig.  43).  In  the  first  position  it  is 
reached  by  an  incision  similar  to  that  employed  for  expos- 
ing the  external  carotid  (Fig.  41).  That  vessel  is  made  evi- 
dent, and  the  hypo-glossal  nerve,  which  winds  round  the 
occipital,  is  demonstrated. 

In  the  second  position  a  nearly  horizontal  incision,  two 
inches  in  length,  is  made,  which,  commencing  about  the  tip  of 
the  mastoid  process,  is  carried  backwards  and  a  httle  upwards. 
The  skin  and  fascia  having  been  divided,  the  muscles  are 
exposed.  The  posterior  fibres  of  the  sterno-mastoid  must  be 
divided;  the  splenius  is  then  cut,  and  so  much  of  the 
trachelo-mastoid  as  may  be  necessary.  The  surgeon  now  feels 
for  the  interval  between  the  mastoid  process  and  the  trans- 
verse process  of  the  atlas,  and  exposes  the  artery  as  it  escapes 
from  beneath  the  digastric  muscle. 

A  good  light  and  suitable  retractors  are  needed  for  this 
operation.  Two  small  venae  comites  attend  the  artery.  Care 
must  be  taken  not  to  injure  the  veins  issuing  from  the  mastoid 
foramen.  The  needle  may  be  passed  either  from  above  or 
from  below. 


172 


CHAPTEE    IV. 

Ligature  of  the  Arteries  of  the  Lower  Limb. 

the  dorsalis  pedis  artery  (iv.-v.). 

Anatomy. — The  artery  extends  from  the  bend  of  the  ankle 
to  the  posterior  end  of  the  first  interosseous  space.  It  lies  on 
the  tarsal  bones — to  which  it  is  attached  by  an  aponeurotic 
layer — between  the  tendons  of  the  extensor  pollicis  and  ex- 
tensor communis  digitorum.  It  passes  beneath  the  lower 
band  of  the  annular  hgament  and  the  dorsal  fascia  of  the 
foot.  Near  its  termination  it  is  crossed  by  the  innermost  slip 
of  the  extensor  brevis  digitorum. 

Two  vense  comites  accompany  the  artery,  and  the  inner 
branch  of  the  anterior  tibial  nerve  lies  to  its  outer  side.  Occa- 
sionally the  nerve  is  superficial  to  the  artery. 

Varieties  of  the  Dorsalis  Pedis  Artery  : 

1.  The  artery  may  be  wanting  and  its  place  be  supplied 

by  the  anterior  peroneal 

2.  It  may  curve  outwards  below  the  ankle-joint,  and 

return  to  its  normal  position  at  the  back  of  the 
first  space. 

3.  It  may  pass  through  the  second  space. 

Line  of  the  Artery. — From  the  centre  of  the  front  of  the 
ankle — the  centre  of  the  inter-malleolar  space — to  the  middle 
of  the  first  interosseous  space. 

Operation. — The  patient  lies  upon  the  back.  The  hmb  is 
straight  and  the  heel  is  steadied  firmly  on  the  table.  The 
surgeon  stands  to  the  outer  side  of  the  hmb  in  each  case, 
cutting  from  above  downwards  on  the  right  side  and  from 
below  upwards  on  the  left.  One  assistant  stands  on  the  op[)o- 
site  side  of  the  table  to  steady  the  limb  and  to  hold  the  foot 
in  the  position  of  full  extension.  Another  assistant  attends  to 
the  woimd. 


LIGATURE    OF   ANTERIOR    TIBIAL    ARTERY.         173 

An  incision,  one  inch  and  a  half  lon^  is  made  on  the  Ime 
of  the  artery,  and  commences  at  the  lower  border  of  the  annu- 
lar ligament.  The  cut  will  be  midAvay  between  the  tendon  of 
the  extensor  pollicis  and  the  innermost  tendon  of  the  ex- 
tensor comnmnis  (Fig.  44).  The  dorsal  fascia  of  the  foot  is 
divided  in  the  same  line.  The  artery — often  buried  in  much 
connective  tissue — is  found  lying  close  to  the  bone.  The  ankle 
should  be  a  httle  relaxed  from  the  extended  posture  as  the 
artery  is  sought  for.  The  needle  should  be  passed  from  the 
outer  side  to  avoid  the  nerve. 

Comment. — The  operation  is  seldom  required  except  to  tie 
a  bleeding  point.  Aneurysm  of  the  dorsalis  pedis  is  not  ex- 
ceedingly rare.  The  tumour  is  usually  placed  over  the 
scaphoid  or  internal  cuneiform  bone.  Ligature  of  the  artery 
above  and  below  the  aneurysm  has  been  fairly  successful.  The 
inner  division  of  the  musculo-cutaneous  nerve  will  be  exposed 
in  the  subcutaneous  tissue,  and  must  be  avoided.  Care  should 
be  taken  not  to  open  the  synovial  sheaths  of  the  two  tendons 
between  which  the  artery  lies.  The  tarsal  branch  of  the  vessel 
arises  opposite  the  head  of  the  astragalus,  and  the  metatarsal 
branch  opposite  the  bases  of  the  metatarsus. 

THE   ANTERIOR   TIBIAL   ARTERY   (iV.). 

Anatomy. — The  vessel  Hes  at  first  close  to  the  inner  side 
of  the  neck  of  the  fibula.  As  it  descends  it  gradually  ap- 
proaches the  tibia,  and  at  the  lower  third  of  the  leg  it  lies  in 
front  of  that  bone.  In  the  upper  two-thirds  of  the  leg,  the 
artery  rests  on  the  interosseous  membrane,  to  which  it  is 
closely  bound  by  connective  tissue.  It  is  at  first  very  deeply 
placed,  but  at  the  lower  third  of  the  hmb  it  becomes  superficial 
For  the  upper  fourth  the  vessel  hes  between  the  tibiahs  anticus 
on  the  inner  side  and  the  extensor  communis  on  the  outer 
side.  From  thence  to  the  lower  end  of  the  middle  third  of 
the  leg  it  hes  between  the  tibiahs  anticus  and  the  extensor 
communis  and  extensor  proprius  poUicis,  the  latter  being 
the  more  deeply  placed.  In  the  lower  third,  where  the 
muscles  become  tendinous,  it  is  crossed  gradually  by  the 
extensor  poUicis  tendon,  which  ultimately  hes  to  its  inner 
side.  The  vessel  here  passes  under  the  upper  band  of  the 
annular  hgament. 


174 


OPERATIVE    8UBGEBY. 


Two  venae  comites  accompany  the  vessel,  one  lying  in  front 
of  tlie  artery,  the  other  behind  it.  The  anterior  tibial  nerve 
lies  first  to  the  outer  side  of  the  artery,  then  (for  the  greater 
part  of  its  course)  more  or  less  in  front  of  the  vessel,  and  lastly 
once  more  to  its  outer  side. 

Line  of  the  Artery. — ^From  a  point  midway  between  the 
head  of  the  fibula  and  the  outer  tuber- 
osity of  the  tibia,  to  the  centre  of  the 
front  of  the  ankle-joint. 

Indications. — The  artery  may  be 
hgatured  at  any  part  of  its  course  on 
the  front  of  the  leg.  The  ligature  in 
the  lower  third  is  the'  most  common. 
It  is  performed  here  for  wound  or  for 
aneurysm.  Ligature  of  the  artery 
above  the  lower  third  is  seldom  called 
for,  and  is  probably  limited  to  cases 
of  wound  only.  Aneurysms  are  rare, 
and  are  most  usually  met  with  at 
either  the  upper  or  the  lower  end  of 
the  artery,  and  not  about  the  middle 
of  its  course.  Ligature  of  the  vessel 
in  its  lower  third  may  be  an  auxiliary- 
measure  in  some  cases  of  bleeding 
from  the  foot  In  punctured  Avounds 
of  the  upper  third  of  the  limb  great 
doubt  may  exist  as  to  'which  artery 
is  divided,  the  anterior  or  the  posterior 
tibial.  In  such  instances  it  is  a 
question  whether  position  and  pres- 
sure, followed  possibly  by  the  distal 
ligature,  do  not  form  a  better  measure 
than  a  widely  extended  dissection  in 
search  of  th(^  bleeding  point. 
1.  Ligature  in  the  Upper  Third  of  the  Leg. 
Position. — The  patient  lies  u])on  the  back.  The  limb  is 
straight  upon  the  table.  The  foot  projects  beyond  the  end  of 
the  table,  and  is  forcibly  extended,  and  (with  the  leg)  fully 
rotated  inwards.  The  surgeon  stands  always  to  the  outer  side 
of  the  limb.     The  incision  for  the  right  artery  is  made  from 


Fifl.  -11.  LIfiATTTRE  OF  THE 
ANTKKIOH  TIBIAL  ARTERY, 
AND  OF  THE  DORSALIS  PEDIS. 


LIGATURE    OF   ANTERIOR    TIBIAL    ARTERY. 


175 


above  doA\Ti ;  for  the  left,  from  below  up.  Two  assistants 
stand  on  the  opposite  side  of  the  table— one  steadies  the 
leg  and  manipulates  the  foot,  the  other  attends  to  the 
wound. 

Operation. — Before  anaesthetising  the  patient,  the  outer 
margin  of  the  tibialis  anticus  should  be,  if  possible,  defined  by- 
causing  the  patient  to  contract  the  muscle. 

An  incision,  three  and  a  half  inches  in  length,  is  made  pre- 
cisely along  the  line  of  the  artery  (Fig.  44).     Its  upper  end  will 
be  about  one  inch  below  the  head  of 
the  tibia.     The  deep  fascia  is  exposed, 
and  is  divided  along-  the  same  line. 
The  interval  between  the  tibialis  an-  ■'. 

ticus  and  extensor  communis  digit-  a—  -- -> 
orum  is  made  out.  The  foot  is  now 
flexed  to  relax  these  muscles.  The 
space  between  them  is  opened  up  by 
means  of  the  linger  and  handle  of 
the  scalpel.  In  doing  this,  the  ex- 
ternal border  of  the  tibia  is  aimed 
for,  and  should  be  distinctly  felt 
before  the  artery  is  sought.  In  pro- 
ceeding towards  this  border,  the 
extensor  communis  is  held  down  by 
the  first  two  fingers  of  the  left  hand, 
while  the  assistant  holds  the  tibiaHs 
anticus  towards  the  tibia  with  a  re- 
tractor. The  outer  border  of  the 
tibia  having  been  made  out  with  the 
forefinger,  the  artery  will  be  found  to 
the  outer  side  of  it,  lying  on  the 
interosseous  membrane.  It  is 
covered  and  held  down  by  a  moder- 
ately dense  connective  tissue.  The  artery  is  now  exposed,  a 
second  retractor  being  used  to  repress  the  extensor  communis 
(Fig.  45). 

The  venae  comites  He  so  close  to  the  artery,  and  in  such  a 
position  {see  page  174),  and  send  so  many  transverse  branches 
across  it,  that  it  is  practically  impossible  to  certainly  separate 
them.     They  wiU  be  probably  enclosed  in  the  ligature.     The 


Fig.  45. — LIGATURE  OF  EIGHT 
AMTEEIOE  TIBIAL  AETEET 
(UPPEE   THIED). 

A,  Fascia  of  leg ;  B,  Tibialis  an- 
ticus ;  c.  Extensor  communis 
digitorum  ;  a,  Anterior  tibial 
artery ;  b.  Anterior  tibial 
veins ;  1,  Anterior  tibial  nerve. 


176  OPERATIVE    SVBGEBY. 

nerve  lies  to  the  outer  side  of  tlie  artery.  The  needle  is  passed 
from  vrithout  inwards. 

The  nerve  may  not  be  seen.  It  may  not  join  the  artery 
until  the  middle  third  of  the  Hmb  is  reached.  It,  however, 
usually  meets  the  vessel  at  the  junction  of  the  upper  with  the 
second  fourth. 

Comment. — The  only  difficulty  in  this  operation  is  the 
finding  of  the  gap  between  the  tibiahs  anticus  and  the  extensor 
communis  digitorum.  Not  the  least  indication  of  it  exists 
upon  the  surface  of  the  deep  fascia.  The  "  white  hne " 
described  by  some  authors  is  a  myth,  so  far  at  least  as  this 
segment  of  the  limb  is  concerned.  On  the  other  hand,  there 
is  a  distinct  septum  between  the  extensor  communis  and  the 
peroneus  longus.  This  is  indicated  by  a  white  line  often 
marked  by  a  deposit  of  fat,  and  also  by  the  escape  of  cuta- 
neous vessels.  The  fascia  to  the  inner  side  of  this  hne  is  dense, 
and  is  composed  of  obHque  fibres  all  running  downwards  and 
inwards.  This  is  the  fascia  covering  the  tibiahs  anticus  and 
the  common  extensor.  The  fascia  to  the  outer  side  of  the 
line — that  covering  the  peronei — is  thinner,  and  made  up 
mainly  of  longitudinal  fibres  crossed  by  a  few  transverse 
streaks. 

In  seeking  the  proper  muscular  interval,  the  following 
points  ma}'  be  observed : — Incise  the  fascia  j)recisely  in  the 
"  line  of  the  artery."  That  hne  corresponds  to  the  gap  between 
the  two  muscles.  In  a  muscular  subject  the  fascia  may  be 
divided  by  a  second  cut  at  right  angles  to  the  first.  Bear  in 
mind  that  the  gap  may  not  be  evident  even  after  a  liberal  turn- 
ing back  of  the  fascia.  The  fibres  of  the  two  muscles  have  the 
same  direction,  and  the  outer  edge  of  the  tibialis  anticus 
may  overlap  the  border  of  the  extensor  communis.  There 
is  usually  a  shght  septum  between  the  two  muscles,  but  it 
is  limited  to  the  upper  third  of  the  hmb,  or  even  the  upper 
fourth  or  upper  sixth.  From  an  operative  point  of  view  it  is 
not  to  be  relied  upon.  The  gap  required  is  to  be  felt  rather 
than  seen.  No  attempt  should  be  made  to  demonstrate  it  by 
cutting.  The  forefinger  and  handle  of  scalpel  should  alone  be 
used.  The  gap  Hes  about  a  finger's  breadth  from  the  septum 
Ijetween  the  extensor  communis  and  the  peroneus  longus,  and 
about  an  inch  or  an  inch  and  a  quarter  from  the  tibial  crest. 


LIGATURE    OF   ANTEIUUR    TIBIAL    ARTERY. 


177 


It  can  be  best  iiiiide  out  by  pressing  the  forefinger  along  the 
muscles  lengthways,  when  it  is  appreciated  as  the  line  of  least 
resistance. 

2.  Ligature  in  the  Middle  Third  of  the  Leg. 

Operation. — The  position  is  the  same  as  in  the  above  opera- 
tion. Make  an  incision  three  inches  in  length  along  the  line 
of  the  artery  (Fig.  44).  The  deep  fascia  is  ex]»osed.  The 
interval   between   the   tibiahs  antieus 

and  extensor  communis   is   indicated  sii 

by  a  yellowish- white  hne.  This  is  due, 
not  to  a  distinct  sejDtum,  but  to  a  line 
of  fatty  tissue  lodged  between  the  two 
muscles.  In  emaciated  subjects  the 
line  may  not  be  apparent.  The  deep 
tascia  is  divided  along  this  Hne.  The 
two  muscles  above-named  are  found 
lying  close  together.  The  outer  edge 
of  the  tibialis  antieus  is  still  muscu- 
lar, but  the  inner  edge  of  the  common 
extensor  is  now  tendinous. 

Flex  the  foot.  Separate  the  mus- 
cles with  the  handle  of  the  scalpel, 
keeping  in  the  direction  of  the  tibia. 
The  artery  is  found  upon  the  interos- 
seous membrane,  with  the  still  deeply 
placed  extensor  poUicis  to  its  outer  side. 
The  nerve  will  be  exposed  before  the 
artery  is  reached,  since  it  here  usually 
lies  in  front  of  the  vessel  The  needle 
may  be  passed  from   either   side.     It 

may  be  impossible  to  separate  the  venae  comites,  but  great 
care  must  be  taken  to  avoid  the  nerve.  In  the  living 
subject  persistent  attempts  to  separate  the  vense  comites  will 
probabl}"  only  lead  to  laceration  of  those  vessels. 

3.  Ligature  in  the  Lower  Third  of  the  Leg. 
Operation. — The  position  is  the  same,  only  the  foot  need 

not  be  so  nuich  rotated  in. 

An  incision,  two  to  two  and  a  half  inches  in  length,  is 
made  in  the  line  of  the  artery,  and  just  to  the  outer  side  of 
the  tendon  of  the  tibialis  antieus 


Fig.  46. — LIGATTJEE  OF  BIGHT 
ANTEEIOB    TIBIAL   (LOWEH 

thied). 

A,  Anterior  annular  liga- 
ment ;  B,  Tibialis  antieus  ; 
c,  Extensor  proprius  pol- 
licis  ;  a.  Anterior  tibial 
artery ;  6,  Anterior  tibial 
veins;  1,  Anterior  tibial 
nerve. 


178  OPERATIVE    SURGERY. 

The  tendon  must  be  identified  beyond  doubt  before  the 
operation  is  proceeded  with.  The  deep  fascia — here  known  as 
the  upper  band  of  the  anterior  annular  hgament — is  divided 
in  the  same  Hne ;  and  the  space  between  the  tibiahs  anticus 
tendon  and  the  tendon  of  the  extensor  pollicis  is  defined. 
Both  these  tendons  will  be  exposed.  The  artery  lies  between 
them,  on  the  front  of  the  tibia,  and  embedded  in  a  consider- 
able quantity  of  fatty  connective  tissue.  The  foot  is  a  little 
flexed,  the  extensor  polhcis  tendon  is  drawn  to  the  outer  side 
by  a  small  blunt  hook,  and  the  exposed  artery  is  easily  secured. 

The  nerve  lies  to  the  outer  side,  and  the  needle  should  be 
passed  from  the  nerve.  As  the  vessel  is  quite  superficial,  the 
venffi  comites  may  be  separated  so  as  to  make  room  for  the 
needle  (Fig.  46). 

Comment. — The  operation  is  without  difficulty  if  one  ten- 
don be  not  mistaken  for  another.  The  nerve  may  lie  in  front 
of  the  artery.  The  two  malleolar  arteries — vessels  about  the 
size  of  the  posterior  auricular — come  off  just  above  the  ankle- 
joint. 

There  are  these  objections  to  the  operation  in  this  situation: 
the  upper  band  of  the  annular  ligament  is  divided,  and  the 
synovial  sheath  of  the  tibiahs  anticus  will  almost  certainly  be 
opened.  This  is  the  only  synovial  sheath  on  the  front  of  the 
hmb  at  this  level. 

Collateral  Circulation  after  Ligature  of  the  Anterior 
Tibial  Artery. 

External  Malleolar  with  Anterior  Peroneal  and  Calcaneal  of  Posterior  Pero- 
neal. 

Internal   Malleolar  with  Internal  Malleolar  of  Posterior  Tibial. 
\  /  Internal  Plantar. 

Dorsalis  Pedis  and  (  )  External  Plantar, 

its  Branches  I     .  'with      1  Antciior  Peroneal. 

'  ^  Calcaneal  of  Posterior  Peroneal. 

Muscular  branches  from  anterior  and  poslirior  tibial  which  anastomose 
after  piercing  the  interosseous  membrane. 

Varieties  of  the  Anterior  Tibial  Artery: 

1.  The  vessel  may  be  wanting,  its  pku;e  being  supphed 

by  perforating  branches  from  the  posterior  tibial. 

2.  It  may  incline  outwards  towards  the  fibula  at  the 

lower  part  of  the  leg,  and  then  return  to  its  ordin- 
ary position  on  the  dorsum  of  the  foot. 


LIGATURE    OF   FOSTERIOR    TIBIAL    ARTERY.        179 

3.  It  may  become  superficial  about  the  middle  of  the 
leg,  and  run  the  rest  of  its  course  covered  only  by 
the  fascia  and  the  skin. 


THE   POSTERIOR   TIBIAL   ARTERY   (ill.). 

Anatomy. — The  vessel  hes  between  the  superficial  and  the 
deep  muscles  of  the  calf,  and  is  closely  bound  to  those  of  the 
latter  group  by  the  deep  fascia  which  covers  them.     At  its 
origin  at  the  lower  border  of  the  popliteus 
muscle,  the  artery  is  opposite  the  inter- 
val   between   the   tibia    and  fibula.      It 
arises  on  a  level  with  the  lower  part  of 
the  tubercle  of  the  tibia,  and  about  two 
inches  below  the  knee-joint.     It  divides 
at  the  lower  border  of  the  inner  annular 
ligament,  on  a  level  with  a  hne  drawn 
from   the   tip   of  the   malleolus  to  the 
centre  of  the  convexity  of  the  heel. 

The  upper  part  of  the  artery  is  very 
deeply  placed  beneath  the  gastrocnemius 
and  soleus  muscles.  In  the  lower  third 
of  the  leg  the  vessel  is  superficial,  being 
covered  only  by  the  skin  and  the  fascia. 
It  lies  successively  on  the  tibialis  post- 
icus, the  flexor  longus  digitorum,  the 
tibia  and  the  ankle-joint.  There  are  two 
vense  comites,  which  he  one  on  either 
side  of  the  artery.  The  posterior  tibial 
nerve  hes  at  first  on  the  inner  side  of 
the  artery.  It  crosses  the  vessel  about 
one  inch  below  the  lower  border  of  the 
popHteus  muscle,  and  rims  for  the  rest 
of  its  course  to  the  outer  side  of  the 
artery. 

Line  of  the  Artery. — A  line  drawn  from  the  centre  of  the 
ham  to  a  point  midway  between  the  inner  malleolus  and  the 
heel  will  correspond  to  about  the  lower  half  of  the  artery.  The 
upper  half  forms  a  slight  curve  inward  from  this  Hne  (Fig.  47). 

Indications. — The  artery  may  be  tied  in  the  leg  or  behind 
the  ankle.     It  is  usually  secured  for  wound.     The  vessel  may 
M  2 


Fig.  47. — LINE  OF  THE 
POPLITEAI/,  POSTEEIOB 
TIBIAL  AND  PEEONEAIj 
AETEEIES  (eight  LIMB). 


180 


OPERATIVE    SURGERY. 


be  ligatured  at  its  lower  end  in  some  cases  of  wound  of  the 
sole. 

In  some  punctured  wounds  of  the  thick  part  of  the  calf 
doubts  may  exist  as  to  which  of  the  deep  vessels  is  wounded. 
In  such  a  case  elevation  of  the  limb,  with  pressure,  followed 
possibly  by  the  distal  ligature,  may  be  a  better  mode  of  treat- 
ment than  an  extensive  dissection  of  a  muscular  limb  in 
search  of  the  bleeding  point.  Laceration  of  this  artery  asso- 
ciated with  fracture  of  the  bone  has  been  successfully  treated 
by  the  distal  ligature  in  Hunter's  canaL 

Aneurysm  is  more  common  in  the  posterior  than  in  the 
anterior  tibial.  Kinloch  had  tabu- 
lated twenty-two  examples  of  spon- 
taneous aneurysm  in  1882.  The 
tumour  usually  occupies  the  upper 
half  of  the  leg.  When  Esmarch's 
bandage,  acute  flexion  of  the  knee, 
and  compression  of  the  femoral 
have  failed,  the  artery  has  been  se- 
cured with  success  above  the  aneur- 
ysm, provided  the  latter  has  been 
placed  low  enough  down. 

1.  Ligature  behind  the   Malle- 
olus. 

Position. — The  patient  lies  on 
the  back.  The  knee  is  flexed,  and 
the  leg  lies  upon  its  outer  side.  The 
foot  lies  upon  the  table  also  on  its 
outer  side,  and  is  secured  in  that 
posture  by  an  assistant.  The  surgeon 
stands  to  the  outer  side  of  the  limb> 
in  either  instance  (right  or  left  hmb). 
Operation. — A  curved  incision, 
two  inches  in  length,  is  inade  about 
half  an  inch  behind  and  parallel  with 
the  margin  of  the  inner  malleolus 
(Fig.  48).  The  knife  is  directed  to- 
wards the  tibia.  The  internal  an- 
nular ligament  is  exposed,  and  divided  over  the  artery.  The 
vessels  and  the  nerve  lie  in  a  gap  between  the  tendons  that- 


Pig.  48.  —  I.KJATURE  OP  THE 
EIGHT  POSTEKIOB  TIBIAL 
AKTERY. 


LIGATURE    OF   FOSTERIOE    TIBIAL    ARTERY 


181 


can  be  appreciated  by  the  touch.  The  artery  having  been 
exposed  and  separated  from  the  veins,  the  needle  is  passed 
from  without  inwards. 

Cotnment. — If  the  veins  are  very  closely  applied  about  the 
artery,  they  may  be  included  in  the  ligature.     In  case  of  high 
division  of  the  trunk,  two  vessels  will  appear,  and  both  will 
require  to  be  secured.     Care  must  be 
taken  not  to  open  the  sheaths  of  the  :■ 

adjacent  tendons.     The  first  canal  in  ,1 

the  annular  hgament  (that  nearest  to  /a\ 

the    malleolus)   contains    the  tibialis  // \\ 

posticus  tendon ;  the  second  contains 
the  tendon  of  the  flexor  longus  digit- 
orum.  Each  of  these  canals  has  a 
separate  synovial  lining.  Then  follows 
a  space  wider  than  that  for  either  of 
the  two  named  canals,  in  which  are 
lodged  the  vessels  and  nerve.  A 
fourth  canal  on  the  astragalus,  Hned 
also  by  a  synovial  membrane,  trans- 
mits the  flexor  longus  pollicis  tendon. 

2.  Ligature  at  the  Lower  Third 
of  the  Leg. 

Operation. — The  position  is  the 
same  as  in  the  previous  operation. 
An  incision,  two  inches  in  length,  is 
made  along  the  Hne  of  the  artery 
midway  between  the  margin  of  the 
tendo  AchiUis  and  the  inner  edge  of 
the  tibia  (Fig.  48).      The  superficial 

and  deep  fasci£e  are  divided,  together  with  the  upper  part  of 
the  inner  annular  ligament.  The  artery  is  found  lying  on 
the  flexor  lonsfus  digitorum  muscle,  with  the  nerve  to  its 
outer  side.  The  needle  is  passed  from  the  nerve.  The  venae 
comites  will  have  to  be  included  if  they  cannot  be  readily 
separated  from  the  artery  (Fig.  49). 

Comment. — The  flexor  longus  digitorum  contains  fleshy 
fibres  until  the  malleolus  is  reached.  The  vessel  Hes  upon  the 
fleshy  part,  and  to  the  outer  side  of  the  tendon. 

The  communicating  branch  between  the  posterior  tibial 


Fig  49  — LIGATURE  OF  EIGHT 
PO^rLRIOll  TIBIAL  ARTEBT 
(LOWER  third;. 

A,  Fascia  of  leg  (internal  an- 
nular ligament)  ;  B,  Flexor 
longus  digitorum  and  ten- 
don ;  C,  Tendo  Achillis  ;  a, 
Posterior  tibial  artery ;  6, 
Posterior  tibial  vein  ;  1, 
Posterior  tibial  nerve. 


182 


OPERATIVE    SURGERY. 


and  peroneal  arteries  arises  an  inch  above  the  ankle-joint. 
The  ligature  will  be  placed  above  this  branch. 

3.  Ligature  in  the  Middle  of  the  Calf/ 

Operation. — The  position  is  the  same  as  in  the  preceding 
operations.  The  calf  of  the  leg  rests  upon  the  table  on  its  outer 
side,  and  the  surcjeon  leans  over  the  limb.  The  incision  is 
made  from  above  downwards  on   the   right   side,  and  from 


Fig.    50.— THE   MODE  OF   DIVIDING  THE  SOLEUS  MUSCI/E  IN  LIGATURE  OF  THE  EIGHT 
POSTERIOR  TIBIAL   ARTERY   IX   THE   MIDDLE  OP   THE  CALF.        (After  Farabeuf.) 


below  up  on  the  left.  The  assistant,  armed  with  retractors, 
stands  on  the  opposite  side  of  the  table. 

An  incision,  four  inches  in  length,  is  made  in  the  middle 
third  of  the  leg,  parallel  to  the  inner  margin  of  the  tibia  and 
three-quarters  of  an  inch  behind  that  crest  of  bone  (Fig.  48) 
The  skin  having  been  divided,  care  must  be  taken  not  to 
wound  the  internal  saphenous  vein,  which  should  be  drawn 
aside.  The  deep  fascia — the  fibres  of  which  are  all  transverse 
— is  exposed  and  divided.  In  a  muscular  subject  the  margin 
of  the  gastrocnemius  may  be  seen. 

The  soleus  is  noAv  exposed,  and  must  be  divided  through 
the  length  of  the  incision.  The  aponruirosis  of  the  muscle  is 
cut  through,  together  with  the  fleshy  fibres  attached  to  it.  In 
making  this  section  the  knife  should  be  kept  perpendicular 


LIGATURE    OF   POSTEllLOR    TIBIAL    ARTERY.        183 

to  the  surface  of  the  muscle.  Its  edge  will  therefore  be  di- 
rected towards  the  tibia,  and  its  blade — in  the  position  in 
which  the  limb  is  held — will  be  nearly  horizontal  (Fig.  50). 
When  the  muscle  has  been  divided,  the  outer  part  must 
be  drawn  well  outwards  by  a  broad  retractor  or  retractors 
held  by  an  assistant.  The  deep  fascia  that  covers  in  the 
vessels  and  the  deep  muscles  of  the  leg  is  now  exposed.  If 
the  finger  be  introduced  the  vessel  can  be  felt.  It  must  be 
remembered  that  the  artery  lies  near  the  outer  border  of  the 
tibia.  When  the  fascia  has  been  divided  (it  is  usually  very 
thin)  the  fleshy  fibres  of  the  flexor  longus  digitorum  are  ex- 
posed. These  fibres  all  run  obliquely  doAvnwards.  By  follow- 
ing the  surface  of  the  muscle  the  vessels  are  reached.  The 
veins  are  very  conspicuous,  and  may  hide  the  artery.  The 
nerve  lies  to  the  outer  side,  and  the  needle  should  be  passed 
from  the  nerve.  It  is  practically  impossible  to  separate  the 
venae  comites  from  the  vessel. 

Comrrient. — This  operation  requires  a  good  light,  and  miay 
be  most  conveniently  done  with  the  aid  of  a  small  electric 
lamp. 

The  tissues  must  be  carefully  retracted,  and  all  the  soft  parts 
draAvn  outwards.  In  using  the  retractors  roughly,  some  fibres 
of  the  flexor  longus  digitorum  may  be  torn  up  and  made  to 
hide  the  artery.  This  may  readily  occur  in  the  cadaver.  If 
in  dividing  the  soleus  the  knife  be  not  kept  towards  the  tibia, 
a  too  extensive  division  of  muscle  results,  and  the  wound  is 
unnecessarily  deepened. 

If  the  section  of  this  muscle  is  made  too  close  to  the  tibia, 
it  is  very  easy  to  get  the  retractor  beneath  the  flexor  digitorum, 
and  the  surgeon  dissecting  on  baneath  that  muscle  may  find 
himself  at  the  interosseous  membrane.  The  soleus  at  the 
point  of  section  is — in  a  fairly  developed  subject — somewhat 
thicker  than  the  little  finger.  The  lateral  tendinous  inter- 
section in  the  substance  of  the  muscle  may  be  encountered 
and  divided.  In  identifying  muscle  it  should  be  remembered 
that  the  fibres  of  the  soleus  in  this  situation  are  attached  only 
along  the  narrow  line  formed  by  the  inner  margin  of  the  tibia. 
The  surgeon  should  not  lose  sight  of  the  fact  that  the  part  for 
which  he  is  aiming  is  in  a  line  with  the  outer  margin  of  the 
tibia. 


184  OPERATIVE    SURGERY. 

Collateral  Circulation  after  Ligature  of  the  Posterior 
Tibial  Artery : 

!{  Posterior  Tibial  by  comtnu- 
with  I  nicating  Branch  and  by 

(  Muscular  Brancbes. 

External  Calcaneal  of  Pero-       ~)  (  Internal  Calcaneal  of  Es- 

neal  j  |  ternal  Plantar. 

External  Malleolar  with  External  Plantar. 

Internal  Malleolar  of  An-         ")      .       (  Internal  Malleolar  of  Post- 

terior  Tibial  j  ^^^      (  erior  Tibial. 

Dorsalis     Pedis     and     its         1      •       (  Internal      and      External 
Branches                                   j             (  Plantar. 

Varieties  of  the  Posterior  Tibial  Artery : 

1.  The  artery  may  be  very  small  at  its  commencement, 

and    be     reinforced    lower    down    by    transverse 
branches  from  the  peroneal. 

2.  It  may  be  wanting  and  be  rej^laced  by  the  peroneal. 

3.  It  may  be  covered  in  the  lower  third  of  the  leg  by 

muscle  which   may  represent  an   accessory  long 
flexor  of  the  toes  or  a  slip  of  the  soleus  (Quain). 

THE   PERONEAL   ARTERY   (ill.). 

Anatomy. — This  vessel  is  the  same  size  as  the  anterior  tibial. 
It  arises  about  an  inch  below  the  lower  border  of  the  popliteus 
muscle.  It  first  inclines  outwards  towards  the  fibula,  resting 
on  the  tibialis  posticus  and  covered  by  the  soleus  and  the  deep 
fascia.  It  then  descends  vertically  along  the  inner  border  of 
the  bone,  under  cover  of  the  flexor  longus  polUcis  (Fig.  47). 
A  little  above  the  middle  of  the  fibula  it  enters  a  fibrous  canal 
between  the  origins  of  the  flexor  longus  poUicis  and  the 
tibialis  posticus.  At  the  lower  third  of  the  leg  the  vessel 
divides  into  anterior  and  posterior  peroneal.  Two  vense 
comites  follow  the  artery.  The  vessel  rapidly  diminishes  in 
size,  and  below  the  middle  of  the  leg  is  often  of  quite  insig- 
nificant dimensions. 

Indications. — The  ligature  of  the  vessel  scarcely  belongs 
to  practical  surgery.  It  may  be — and  has  been — secured  for 
wound,  and  is  in  such  a  case  reached  through  the  wound 
already  made. 

The  artery  may  in  rare  cases  be  of  large  size,  and  found  to 
reinforce  a  small  posterior  tibial 


LIGATURE    OF   POPLITEAL    ARTERY.  185 

Ligature  about  the  Middle  of  the  Leg. 

Operation. — The  jJJ^tieiit  lies  upon  the  sound  side,  almost 
upon  the  abdomen.  The  knee  is  a  little  flexed,  and  the  leg 
lies  upon  its  antero-internal  surface,  being  held  firmly  upon 
the  table  by  an  assistant. 

An  incision,  three  and  a  half  inches  in  length,  is  made 
parallel  with  and  immediately  behind  the  outer  border  of  the 
fibula.  The  centre  of  the  incision  corresponds  to  the  middle 
of  the  leg.  The  fascia  having  been  divided,  the  soleus  muscle 
is  exposed.  At  the  site  of  the  operation  the  muscle  will  have 
ceased  to  arise  from  the  fibula.  (It  takes  origin  from  the 
upper  third  only  of  that  bone.)  The  muscle  must  be  drawn 
inwards,  and  any  portion  of  its  attachment  to  the  fibula  in  the 
upper  part  of  the  wound  is  divided  if  necessary.  The  fibula 
will  now  be  distinctly  exposed.  The  fibres  of  the  flexor  longus 
pollicis  are  then  to  be  severed  close  to  the  fibula,  until  the 
membranous  wall  of  the  canal  containing  the  vessel  is  exposed. 
This  is  carefully  laid  open,  and  the  artery  is  found  lying  against 
the  inner  margin  of  the  bone. 

The  needle  may  be  most  conveniently  passed  from  the 
outer  side,  and  will  probably  take  up  also  the  venas  comites. 

The  muscular  tissue  must  be  well  held  aside  by  retractors, 
as  the  wound  is  deep. 

THE   POPLITEAL   ARTERY    (L-IL). 

Anatomy. — The  vessel  extends  from  the  opening  in  the 
adductor  magnus  to  the  lower  border  of  the  popHteus  muscle, 
passing  through  the  centre  of  the  popliteal  space.  From  its 
commencement  to  a  point  behind  the  middle  of  the  knee- 
joint,  the  artery  inchnes  from  within  outwards ;  beyond  this 
point  it  descends  vertically  (Fig.  47).  The  artery  is  deeply 
placed.  Its  upper  end  is  covered  by  the  semi-membranosus 
muscle,  its  lower  end  by  the  gastrocnemius.  Between  these 
points  it  lies  deeply  in  the  popliteal  space.  The  popliteal  vein 
lies  close  to  the  artery.  It  is  placed  at  first  to  the  outer  side, 
and  a  little  behind  the  artery ;  it  then  gradually  crosses  over 
that  vessel,  and  ultimately  gains  its  inner  side.  This  vein  is 
remarkably  substantial,  and  has  walls  so  thick  and  dense  that 
in  section  they  look  not  unlike  the  tunics  of  an  arter}-.     It  is, 


186  OPERATIVE    SUEGEBY. 

moreover,  very  closely  adherent  to  the  artery.      It  may  be 
double  along  the  lower  part  of  its  course. 

The  internal  popliteal  nerve  is  at  first  to  the  outer  side  of 
the  artery,  and  superficial  to  it.  It  then  crosses  gradually  over 
the  vessels,  and  hes  behind  and  to  the  inner  side  of  them,  below 
the  joint.  The  nerve  is  throughout  separated  from  the  artery 
by  the  vein.  In  the  centre  of  the  ham  the  nerve  and  veui 
he  exactly  over  the  artery. 

The  crease  in  the  skin  which  crosses  the  popliteal 
space  transversely  is  some  way  above  the  line  of  the  knee- 
joint. 

The  guide  to  the  upper  part  of  the  artery  is  the  outer 
border  of  the  semi-membranosus.  The  popliteal  ends  on  a 
level  with  the  lower  part  of  the  tubercle  of  the  tibia. 

Indications. — The  conditions  which  would  justify  Hgature 
of  the  popliteal  artery  are  exceedingly  few.  If  a  hgature  be 
required  in  dealing  with  aneurj^sm  of  the  leg,  the  femoral  would 
be  secured.  So  many  and  so  exceptional  difliculties  attend 
the  operation  of  Antyllus  in  cases  of  pophteal  aneurysm  that 
most  surgeons  prefer  to  deal  with  such  cases  by  amputation 
when  other  means  have  failed. 

The  popliteal  may  be  ligatured  in  some  cases  of  wound,  e.g., 
a  wound  received  from  the  chisel  in  performing  osteotomy. 
^lacCormac  considers  it  may  be  ligatin-ed  "  possibly  for  a 
small  recent  traumatic  aneurysm." 

The  artery  may  be  secured  at  its  upper  or  at  its  lower  part. 
In  the  middle  of  its  course  it  Avould  scarcely  be  exposed  surgi- 
cally. The  vessel  is  here  very  deeply  placed,  is  surrounded  by 
much  fat,  is  covered  by  the  vein  and  the  nerve,  is  giving  off 
numerous  branches,  and  is  very  close  to  the  synovial  mem- 
brane of  the  loiee-joint. 

Even  as  a  dissecting-room  operation,  the  ligature  of  the 
artery  at  its  middle  third  has  little  to  recommend  it. 

1.  Ligature  of  the  Lower  Part  of  the  Artery. 

Operation. — The  patient  is  so  rolled  over  as  to  rest  upon 
the  shoulder  and  one  side  of  the  chest,  and  is  indeed  made  to 
lie  as  nearly  prone  as  the  circumstances  attending  the  adminis- 
tration of  an  anaesthetic  will  permit.  Tlic  limb  is  fully  ex- 
tended. The  surgeon  will  stand  to  the  outer  side  of  the  left 
limb  and  to  the  inner  side  of  the  right.     The  chief  assistant 


LIGATURE    OF   POPLITEAL    ARTERY. 


187 


is  placed  opposite  to  him.     In  the  case  of  either  extremity  the 
incision  is  made  from  above  downwards. 

A  vertical  incision — from  three  to  three  and  a  half  inches 
m  length — is  made  over  the  back  of  the  limb,  commencing 
opposite  to  the  centre  of  the  popliteal  space  (i.e.,  the  level  of 
the  Icnee-joint),  and  extending  downwards  over  the  interval 
betAveen  the  two  heads  of  the  gastrocnemius  muscle. 

The  skin  and  superficial  fascia  having  been  divided,  care 
must  be  taken  not  to  damage  the  short  saphenous  vein  and 
nerve.  These  structures  will 
appear  at  the  outer  part  of  the 
wound,  and  should  be  drawn 
outwards.  The  deeper  fascia  is 
divided  in  the  same  vertical 
line. 

The  heads  of  the  gastrocne- 
mius muscle  are  now  exposed, 
and  the  surgeon  follows  the  in- 
terval between  them.  On  each 
side  of  this  gap  a.  sural  artery 
will  be  found,  accompanied  by 
the  nerve  to  the  corresponding- 
head  of  the  muscle. 

Deep  in  the  interval  itselt 
the  large  nerve  to  the  soleus 
muscle  (from  the  internal  popli- 
teal) will  probably  be  met  with, 
and  must  be  drawn  aside.  It 
usually  lies  directly  in  the  hne 
of  the  operation. 

Following  the  short  saphen- 
ous vein,  the  surgeon  is  guided 
to  the  popliteal  vessels.  This 
part  of  the  operation  is  rendered  easier  by  flexing  the  knee- 
joint  a  little  so  as  to  relax  the  gastrocnemius.  The  internal 
popliteal  nerve  is  first  encountered,  then  the  vein  and  the 
artery.  The  two  first-named  structures  are  drawn  to  the  inner 
side.  The  artery  is  cleared,  and  the  needle  is  passed  from 
the  inner  side  (Fig.  51). 

2.  Ligature   of  the   Upper   Part  of  the   Artery. — This 


Fig.      51. — LIGATIEK     OF     RIGHT 
POPLITEAL    (lower   PART). 

A,  Fascia ;  B,  Gastrocnemius  ;  a,  Pop- 
liteal artery  ;  b,  Popliteal  vein  ;  c, 
External  saphenous  vein  ;  1,  Inter- 
nal popliteal  nerve  ;  2,  Muscular 
branches ;  3,  External  saphenous 
nerve. 


188  OPERATIVE    SURGE  BY. 

operation — known  as  Jobert's  operation  for  the  ligature  of  tlie 
popliteal  artery  {ISfoiivelle  Bihliotheque  Med.,  Feb.,  1827) — is 
carried  out  in  the  thigh.  The  vessel  is  secured  close  to  the 
inner  side  of  the  femur,  and  is  reached  between  the  semi- 
membranosus muscle  and  the  tendon  of  the  adductor 
magnus. 

Operation. — The  patient  lies  upon  the  back,  vAth.  the  hip  a 
Uttle  flexed  and  the  thigh  fully  abducted  and  rotated  outwards. 
The  knee-joint  is  bent  at  a  right  angle,  and  the  knee  and  leg 
are  thus  made  to  he  upon  the  outer  side. 

The  surgeon  stands  to  the  outer  side  of  the  extremity  in 
either  case.  The  incision  on  the  right  side  is  made  from 
above  downwards,  and  on  the  left  from  below  upwards.  The 
chief  assistant  faces  the  operator. 

The  incision  is  three  inches  in  length,  is  commenced  at  the 
junction  of  the  middle  with  the  lower  thirds  of  the  thigh,  and 
is  parallel  with  and  just  posterior  to  the  tendoa  of  the  adductor 
magnus.  The  position  of  this  tendon  should  have  been  well 
defined  (Fig.  52). 

After  the  skin  has  been  divided,  there  will  probably  be 
found  in  the  subcutaneous  fat  the  anterior  division  of  the  in- 
ternal cutaneous  nerve,  which  hes  usually  in  the  direct  line 
of  the  operation.     It  should  be  dra^vn  aside. 

The  anterior  edge  of  the  sartorius  muscle  is  next  exposed, 
and  the  whole  muscle  must  be  displaced  backAvards. 

Upon  this  muscle  at  this  point  will  he  the  internal 
saphenous  vein.  The  vessel  may  possibly  be  exposed,  in 
which  case  it  is  drawn  backwards  with  the  sartorius. 

The  trunk  of  the  internal  saphenous  nerve  is  not  en- 
countered.    It  lies  beneath  the  sartorius. 

The  deep  fascia  having  been  well  divided,  the  tendon  of  the 
adductor  magnus  is  sought  for,  and  is  drawn  forwards  with  a 
blunt  hook.  The  semi-membranosus  muscle  is  next  exposed, 
and  is  drawn  backwards  with  a  retractor.  The  operator  now 
seeks  for  the  artery  in  the  interval  between  the  two  structures. 
The  vessel  wiU  be  surrounded  by  much  connective  tissue,  and 
is  lying  close  to  the  bone.  The  internal  popliteal  nerve  is  here 
at  some  distance  from  the  vessel,  and  will  not  be  seen.  The 
vein  also  is  not  necessarily  exposed.  It  lies  posterior  to  the 
artery,  and  to  its  outer  side.     Indeed,  as  approached  from  this 


LIGATURE    OF   FEMORAL    ARTERY.  189 

point  the  artery  is  the  most  superficial  of  the  three  structures 
named. 

When  the  vessel  has  been  properly  exposed,  the  needle 
may  be  passed  from  below  upwards. 

An  aneurysm  needle  with  a  large  lateral  curve  will  be 
found  the  most  convenient. 

In  performing  this  operation  care  must  be  taken  not  to 
wound  the  deep  branch  of  the  anastomotica  magna  artery, 
which  runs  along  the  anterior  surface  of  the  adductor  magnus 
tendon. 

Collateral  Circulation  after  Ligature  of  the  Popliteal 
Artery. 

The  inferior  articular  arteries,  the  anterior  tibial  recurrent  (with  possibly 
the  posterior  tibial  recurrent  and  superior  fibular  branches  of  the  anterior  tibial), 
beloiv  the  ligature  communicate  with  the  superior  articular  artei'ies,  the  anasto- 
motica magna  and  external  circumflex  arteries  above  the  ligature. 

Muscular  branches  will  also  take  part  in  establishing  the  new  circulation. 

Varieties  of  the  Popliteal  Artery. — This  artery  is  very 
seldom  found  to  deviate  from  the  normal  condition.  The 
only  variety  which  is  at  all  common  is  the  high  division  of 
the  vessel  into  its  terminal  branches.  Such  division  may  take 
place  opposite  the  knee-joint  or  even  behind  the  intercondyl- 
oid  fossa  of  the  femur. 

THE    FEMORAL   ARTERY. 

Anatomy. — The  diameter  of  the  common  femoral  is  from 
9  to  10  m.m.,  the  superficial  femoral  is  the  size  of  the  carotid 
artery  and  the  profunda  of  the  brachial. 

At  the  groin  the  artery  is  in  front  of  the  summit  of  the 
head  of  the  fenun-.  At  its  lower  end  it  lies  close  to  the  inner 
surface  of  the  shaft  of  the  femur.  Between  these  points  it  is 
placed  at  some  httle  distance  from  the  bone. 

The  vessel  lies,  in  order  from  above  downwards,  upon  the 
psoas,  pectineus,  adductor  brevis,  adductor  longus,  and  the 
tendon  of  the  adductor  magnus. 

The  femoral  lies  at  first  in  Scarpa's  triangle,  where  it  is 
superficial  The  apex  of  this  triangle  is  from  three  to  three 
and  a  half  inches  below  Poupart's  ligament. 

The  vessel  then  enters  Hunter's  canal,  which  occupies  the 
middle  third  of  the  limb. 


190  OPERATIVE    SURGERY. 

In  this  canal  are  the  artery  and  vein,  the  internal 
saphenous  nerve,  and  the  superficial  part  of  the  anastomotica 
magna  artery. 

The  profunda  femoris  arises  one  inch  and  a  half  below 
Poupart's  ligament,  and  the  two  circumflex  arteries  some  two 
inches  below  that  structure. 

At  the  groin  the  femoral  vein  is  upon  the  same  plane  as 
the  artery,  and  to  its  inner  side.  At  the  apex  of  Scarpa's  tri- 
angle the  vein  is  behind  the  artery.     In  Hunter's  canal  it  lies 


Fig.  52. — LIGATUKE  OF  THE  EIGHT  COMMON  FKMOKAL  AT  THE  BASE  OP  SCARPA'S 
TBIANGLE  ;  OF  THE  FEMORAL  AT  THE  APEX  OF  SCARPA'S  TRIANGLE  AND  IN 
hunter's   canal,    AND   OF    THE   UPPEE   PART  OP  THE  POPLITEAL. 

behind,  and  a  little  to  the  outer  side.  The  vein  is  throughout 
very  close  to  the  artery. 

At  the  aj^cx  of  Scarj^a's  triangle  both  the  femoral  and  the 
profunda  veins  separate  the  two  corresponding  arteries ;  the 
order  from  before  backwards  being — the  femoral  artery,  the 
femoral  vein,  the  profunda  vein,  the  profunda  artery. 

The  anterior  crural  nerve  lies  well  to  the  outer  side  of  the 
artery  at  the  groin.  The  internal  cutaneous  nerve  cvosses  the 
vessel  at  the  upper  edge  of  the  sartorius.  The  internal  saphe- 
nous nerve  comes  in  front  of  the  artery,  just  above  the  middle 
of  the  thigh,  and  lies  in  front,  and  a  little  to  the  outer  side  of 
it,  in  Hunter's  canal. 

The  course  of  the  long  saphenous  vein  may  be  roughly 


LIGATURE    OF   FEMORAL    ARTERY.  191 

represented  by  a  line  drawn  from  a  point  about  three-quarters 
of  an  inch  to  the  inner  side  of  the  Hne  of  the  femoral  artery  at 
the  groin,  to  the  posterior  border  of  the  sartorius  muscle,  at  the 
level  of  the  condyle  of  the  femur. 

Line  of  the  Artery. — The  hip  being  a  httle  flexed  and  the 
thigh  abducted  and  rotated  outwards,  a  line  is  drawn  from  a 
point  midway  between  the  anterior  superior  spine  of  the  ilium 
and  the  symphysis  pubis,  to  the  tuberosity  of  the  internal  con- 
dyle (Fig.  52).  The  centre  of  Poupart's  ligament  is  entirely  to 
the  outer  side  of  the  line  of  the  vessels. 

Indications. — -The  superficial  femoral  may  be  ligatured  in 
Hunter's  canal  or  at  the  aj^ex  of  Scarpa's  triangle.  The  com- 
mon femoral  may  be  ligatured  at  the  base  of  that  triangle. 

The  only  one  of  these  three  operations  which  is  performed 
with  any  degree  of  frequency  is  the  hgature  at  the  apex  of 
Scarpa's  triangle.  This  is  called  the  "  place  of  election,"  and 
in  any  case  in  which  "ligature  of  the  femoral"  is  advised  or  is 
mentioned,  it  is  assumed  that  the  vessel  is  secured  at  this 
point. 

A  ligature  may  be  applied  here  in  certain  cases  of  popliteal 
and  lower  femoral  aneurysm  which  have  resisted  simpler  treat- 
ment, and  in  certain  cases  of  wound. 

The  femoral  has  been  tied  at  this  point  also  for  the  relief 
of  elephantiasis  Arabum. 

A  ligature  is  very  rarely  indeed  applied  to  the  common 
femoral.  Great  risks  attend  the  procedure.  The  risk  of  gan- 
grene is  considerable,  as  is  also  that  of  secondary  haemorrhage. 
The  operation  has  proved  to  be  more  dangerous  when  the 
vessel  is  secured  between  the  deep  e^jigastric  and  profunda 
arteries  than  when  it  is  ligatured  either  above  or  below  those 
branches. 

The  numerous  small  vessels  which  arise  from  the  common 
femoral,  the  proximity  of  the  profunda,  and  the  occasional 
high  origin  of  that  vessel  or  of  one  of  the  circumflex  arteries, 
render  a  sound  occlusion  of  the  main  artery  a  matter  of  un- 
certainty. In  most  of  the  circumstances  in  which  a 
ligature  of  the  common  femoral  might  be  suggested,  the 
securing  of  the  external  iliac  artery  is  the  better  procedure 
in  actual  practice. 

The  common  femoral  is  secured  as  a  preliminary  measure 


192  OPERATIVE    SURGE  BY. 

in  some  amputations  at  the  liip  joint,  and  in  certain  cases 
of  wound. 

The  ligature  in  Himter's  canal  has  been  employed  in  cases 
of  wound,  in  some  exceptional  examples  of  aneur^^sm,  and  in 
bleeding  from  the  stump  after  amputation  through  the  lower 
part  of  the  thigh.  John  Hunter  was  the  first  surgeon  to 
apply  a  ligature  to  this  part  of  the  artery  for  popliteal 
aneurysm.     The  operation  was  performed  in  1785. 

Position. — The  patient  lies  upon  the  back,  with  the  hip 
a  httle  flexed,  mth  the  thigh  abducted  and  rotated  outwards, 
with  the  knee  bent  and  the  leg  resting  upon  its  external 
surface. 

The  surgeon  stands  to  the  outer  side  of  the  Hmb  in  either 
case,  and  the  chief  assistant  is  placed  opposite  to  him.  The 
incision — in  the  case  of  the  right  thigh — is  made  fi*om  above 
do'WTLwards,  and  in  the  case  of  the  left  fiom  below  upwards. 

Ligature  of  the  Superficial  Femoral  in  Hunter's  Canal. 

Operation. — The  hmb  having  been  placed  as  already  mdi- 
cated,  an  incision  three  and  a  quarter  inches  in  length  is  made 
along  the  line  of  the  artery  in  the  middle  third  of  the  thigh 
(Fig.  52). 

In  the  layer  of  subcutaneous  tissue  the  anterior  division 
of  the  internal  cutaneous  nerve  will  probably  be  met  with, 
and  to  the  inner  side  of  it  the  long  saphenous  vein.  This 
vessel  must  be  drawn  inwards. 

The  fasica  lata  is  now  divided  in  the  Hne  of  the  original 
wound,  and  the  sartorius  is  exposed.  This  muscle  must  be 
clearly  identified.     Its  fibres  run  do^vnwards  and  inwards. 

The  anterior  or  outer  edge  of  the  muscle  having  been 
exposed,  the  whole  structure  is  drawn  inwards  with  a  suitable 
retractor. 

The  site  of  Hunter's  canal,  lying  between  the  adductor 
masnus  and  the  vastus  internus,  can  now  be  weU  defined, 
especially  if  the  fibres  of  the  gi*eat  adductor  and  the  lower 
border  of  the  adductor  longus  are  made  prominent  by  fully 
abducting  the  thigh. 

When  any  fatty  tissue  which  may  obscure  the  part  has 
been  cleared  away,  the  fascia  which  forms  the  roof  of  Hunter's 
canal  is  rendered  distinct.  The  fibres  forming  this  fascia  are 
arranged  transversely. 


LIGATURE    OF   FEMORAL    ARTERY. 


193 


C-„ 


At  this  point  there  may  be  exposed,  at  the  outer  side  of 
the  wound,  the  nerve  to  the  vastus  internus. 

The  canal  is  opened  in  the  hne  of  the  original  wound,  and 
the  artery  exposed  (Fig.  53). 

The  needle  may  be  passed  from  *#  ^ 

either  side. 

In  front  and  to  the  outer  side  of 
the  vessel  will  be  found  the  internal 
saphenous  nerve,  which  is  easily 
avoided. 

Care  must  be  taken  that  the 
vein  be  not  damaged  in  passing 
the  needle  round  the  artery. 

Gomiment. — The  cut  is  apt  to  be 
made  too  far  outwards,  in  which 
<3ase  the  vastus  internus  is  exposed 
instead  of  the  sartorius,  and  the 
one  muscle  may  be  mistaken  for  the 
other.  Their  libres,  however,  run  in 
opposite  directions,  those  of  the 
vastus  dowuAvards  and  outwards, 
those  of  the  sartorius  downwards 
and  inwards. 

The  incision  may  be  made  too 
low  down,  and  the  poj)liteal  artery 
be  reached. 

In  making  the  skin  wound  care- 
lessly the  internal  saphenous  vein 
has  been  cut  into. 

The  whitish  tendon  of   the  adductor  magnus  has 
mistaken  for  the  artery  in  the  dead  subject. 

Farabeuf  recommends  that  as  soon  as  the  sartoriu 
muscle  has  been  dra^vn  aside,  the  thigh  should  be  AveL 
abducted  and  rotated  out,  so  as  to  bring  into  prominence 
a  tendinous  cord — la  corde  qui  vihre — which  is  derived  from 
the  lower  fibres  of  the  adductor  longus,  and  is  passing  to  the 
general  adductor  insertion.  This  cord  helps  to  define  the 
canal,  and  the  incision  is  made  first  to  its  outer  side. 

2.  Ligature  of  the  Superficial  Femoral  at  the  Apex  of 
Scarpa's  Triangle. 


OF      RIGHT 


Fig.      .53.— LIGATURE 

FEMORAL  ARTERY  IN  HUNTER'S 
CANAL. 


Fascia  lata  ;  B,  Sartorius  ;  C, 
Vastus  internus;  n,  Fascia 
closing  in  Hunter's  canal ;  E, 
Sheath  of  artery  ;  a.  Femoral 
artery ;  1,  Long  saiiheuous 
nerve  ;  2,  Anterior  branch  of 
internal  cutaneous  nerve. 


been 


194 


OPERATIVE    SURGERY. 


Operation. — The  limb  is  placed  in  the  position  already 
indicated,  and  the  line  of  the  artery  is  marked  out. 

An  incision  three  inches  in  length  is  made  along  this  line 
as  it  crosses  the  apex  of  Scarpa's  triangle.  The  centre  of  the 
wound  should  correspond  to  the  apex,  and  the  incision,  there- 
fore, will  reach  to  within  one  and  a  half  or  two  inches  of 
Poupart's  ligament  (Fig.  52). 


A  large   tributary   of  the 


-c 


internal  saphenous  vein  will 
usually  be  exposed,  and  if  it 
cannot  be  drawn  easily  aside 
it  should  be  divided  between 
two  ligatures. 

The  fascia  lata  having 
been  divided  in  the  oJginal 
line,  the  sartorius  is  exposed 
at  the  outer  part  and  inferior 
end  of  the  wound,  its  fibres 
running  downwards  and  in- 
wards. 

Its  inner  border  should 
be  well  isolated,  and  the 
whole  muscle  is  then  drawn 
outwards. 

The  operator  now  feels 
for  the  groove  of  the  artery. 
In  front  of  the  vessel  will  be 
found  branches  of  the  in- 
ternal cutaneous  nerve,  and 
deeper  and  to  its  outer  side 
are  the  long  saphenous  nerve, 
and,  possibly,  the  nerve  to 
the  vastus  internus  (Fig. 
54). 

The  sheath  of  the  vessel 
should  be  weU   opened,  and 

the  needle  passed  from  the  inner  side. 

Comment. — Scarpa's  triangle  is  much  smaller  than  would 

appear  to  be  the  case  when  the  dissected  region  is  inspected. 

There    may    be    no  more    than    two    inches    of   the    artery 

left    uncovered    by    the    sartorius    muscle.      An    unusually 


Fig.  .54.— LIGATURE  OF  RIGHT  FEMORAL 
ARTEKY  AT  APEX  OF  SCARPA'S  TRI- 
ANGLE. 

A,  Fascia  lata ;  B,  Sartorius  ;  C,  Adductor 
longus ;  I),  Hheath  of  artery ;  n,  Fe- 
moral artery  ;  h,  Tributary  to  internal 
saphenous  vein  ;  1,  Long  saphenous 
nerve  ;  2,  Internal  cutaneous  nerve. 


LIGATURE    OF   FEMORAL    ARTERY. 


195 


B- 


broad  sart(irins  adds  a  little  to  the  difficulty  of  the  opera- 
tion. 

In  order  to  reach  the  edge  of  the  sartorius  muscle 
easily,  the  cut  is  oft'i  made  too  much  to  the  inner  side, 
with  the  result  that  the  great  saphenous  vein  is  cut  into. 
On  the  other  hand,  if  the  thigh  be  not  placed  in  proper 
position,  the  incision  is  apt  to  fall  too  much  to  the  outer  side. 

The  special  danger  of  the  operation  consists  in  the  wound- 
ing of  the  vein  in  passing  the  needle.  The  greatest  care 
must  be  taken  to  open  the  sheath  of  the  artery  well,  and  to 
keep  the  point  of  the  needle  close  to  the  arterial  wall. 

An  aneurysm  needle,  curved 
laterally,  will  usually  be  found  the  / 

more  convenient.  ////    ^ 

•S.  Ligature  of  the  Common 
Femoral  at  the  base  of  Scarpa's 
Triangle. 

Operation.  —  The  position  of 
the  surgeon  and  of  the  patient 
has  been  already  indicated.  An 
incision  two  inches  in  length  is 
commenced  a  little  above  Pou- 
part's  ligament  {i.e.,  on  the  abdo- 
men), and  is  carried  downwards 
parallel  with  the  line  of  the  artery 
(Fig.  52)._ 

In  dividing  the  layer  of  fatty 
tissue  which  covers  the  fascia  lata, 
care  must  be  taken  not  to  injure 
any  of  the  lymphatic  glands  of 
the  region,  and  to  avoid  the  super- 
ficial veins,  notably  the  superficial 
epigastric  and  superficial  circum- 
flex iliac.  The  cribriform  fascia  is 
now  divided  in  the  original  line,  and  especial  care  must  be 
taken  not  to  wound  the  superficial  arteries,  the  two  which 
usually  come  nearest  to  the  incision  being  the  superior  exter- 
nal pudic  and  the  superficial  epigastric. 

The  crural  branch  of  the  genito-crural  nerve  lies  upon  the 
sheath  of  the  artery,  but  upon  the  outer  side  of  the  vessel. 
N  2 


Fig.     .55.   —  LIGATURE     OP     RIGHT 

common  femohal  at  base  of 
scakpa's  triangle. 

A,  Line  of  Poupart's  ligament ; 
B,  Superficial  fascia  ;  c.  Fascia 
lata;  p,  Slieath  ;  ((,  Femoral 
art. ;  h.  Femoral  vein  ;  c,  Int. 
saphenous  vein ;  1,  Genito- 
crural  nerve. 


196  OPERATIVE    SURGERY. 

The  slieath  being  clearly  exj)osed  and  caretiilly  opened, 
the  needle  is  passed  from  the  inner  side  (Fig.  55). 

Comment. — By  starting  from  the  level  of  the  centre  of 
Poupart's  ligament,  the  incision  is  placed  to  the  outer  side  of 
the  line  of  the  vessels,  and  the  vein  is  thus  more  certainly 
avoided.  AVlien  the  vein  is  at  all  distended,  it  is  apt  to 
overlap  the  artery. 

Collateral  Circulation  after  Ligature  of  the  Femoral 
Artery. 

(a)  After  Ligature  of  the  Common  Fe'tnoral : 


Above. 

Below. 

Internal  pudic 

with 

Pudic  of  femoral. 

Gluteal 

with 

External  circumflex,  internal  circumflex,  and 
first  perforating. 

Circumflex  iliac 

with 

External  circumflex. 

Obtui-ator 

with 

Internal  circumflex. 

Sciatic 

with 

Superior  perforating  and  internal  circumflex. 

Comes  nervi  iscMadici 

with 

Perforating. 

(b)  After 

Ligature  of 

the  Superficial  Femoral : 

Above. 

Below. 

External  ciicumflex 

with 

Lower  muscular  branches  of  femoral,  anas- 

tomotica  magna,  and  superior  articular 
branches  of  popliteal. 
Perforating  arteries -j  /-Muscular    branches    of   the   femoral  and 

and  termination  of  >  with  <  popliteal  and   the  superior  articular 

profunda.  )  C         arteries. 

A  communication  is  effected  along  the  back  of  the  thigh, 
between  the  sciatic  artery,  the  terminal  branches  of  the  mter- 
nal  circumflex,  the  perforatmg  arteries,  and  the  branches  of 
the  popUteal.  "In  several  instances  in  which  the  condition 
of  the  vessels  has  been  examined  after  hgature  of  the  femoral 
(or  external  iHac)  artery,  the  comes  nervi  ischiadici  has  been 
found  much  enlarged,  forming,  with  anastomotic  branches 
from  the  perforating  arteries,  a  vessel  which  accompanies  the 
great  sciatic  nerve,  and  ends  below  in  the  pophteal  artery,  or 
one  of  its  branches."     (Quain.) 

Varieties  of  the  Femoral  Artery. — 1.  The  femoral  may 
divide  below  the  origin  of  the  profunda  into  two  vessels, 
which  reunite  again  at  a  variable  distance  above  the  opening 
in  the  adductor  magnus  to  form  a  single  ])opliteal  artery. 


LIGATURE    OF   FEMORAL    ARTERY.  197 

2.  A  vas  aberrans  may  leave  the  external  iliac  artery,  and 
running  by  the  inner  side  of  the  common  femoral  artery,  may 
join  the  superficial  femoral  about  the  apex  of  Scarpa's  triangle. 

3.  The  main  artery  of  the  limb  may  be  found  wholly  at 
the  back  of  the  thigh,  and  be  derived  from  a  gi-eatly  enlarged 
sciatic  artery. 

4.  The  profunda  may  arise  from  the  inner  or  from  the 
posterior  side  of  the  main  vessel,  and  may  take  origin  less 
than  one  inch  or  more  than  two  inches  below  Poupart's 
ligament. 

5.  The  circumflex  arteries  may  arise  in  whole  or  in  part 
from  the  femoral.  This .  especially  applies  to  the  internal 
circumflex. 

6.  The  femoral  may  give  off  the  deep  epigastric,  the  cir- 
cumflex ihac,  or  the  great  saphenous  artery.  The  last  named 
vessel  arises  above  or  below  the  origin  of  the  profunda,  and 
passing  along  Hunter's  canal,  becomes  superficial  at  the  inner 
side  of  the  knee,  and  follows  the  internal  saphenous  vein  to 
the  ankle. 


1198 


CHAPTER    V. 

Ligature  of  the  Iliac  Arteries,  and  of  the  Abdomina. 

Aorta. 


THE   external   ILIAC    ARTERY. 

Anatomy. — This  vessel  extends  from  the  bifurcation  of  the 
common  ihac,  at  the  lumbo-sacral  articulation,  to  Poupart's 
hgament,  measures  from  three  and  a  half  to  four  inches  in 
length,  and  has  a  diameter  of  from  9  to  10  m.m. 

The  artery  lies  upon  the  iliac  fascia,  with  which  it  is  con- 
nected by  a  thin  sheath  derived  from  the  subperitoneal  tissue. 

It  runs  along  the  inner  margin  of 
the  psoas  muscle,  and  at  Poupart's 
ligament  is  placed  actually  upon  that 
muscle. 

It  is  covered  by  peritoneum. 
The  sigmoid  flexure  crosses  it  on  the 
left  side,  and  the  terminal  part  of 
the  ileum  on  the  right.  The  ureter 
passes  over  the  vessel  at  the  point 
of  bifurcation  of  the  common  iliac. 

About  three-quarters  of  an  inch 
above  Poupart's  ligament  the  artery 
is  crossed  by  the  circumflex  iliac 
vein  (represented  at  this  point  by  a 
single  trunk). 

Passing  over  the  lower  part  of 
the  artery  are  the  spermatic  vessels,  and  the  vas  deferens, 
which  latter  curves  round  the  deep  epigastric  artery. 

The  genital  branch  of  the  genito-crural  nerve  lies  upon 
the  artery  at  its  outer  side.  Some  lymphatic  glands  and  not 
a  few  lymphatic  vessels  lie  upon  or  about  the  vessel. 

The  deep  epigastric  artery  arises  about  one-fourth  of  an 
inch  above  Pou])art's  ligament,  and  runs  between  the  trans- 


Fig.  .o6.— RELATION  OF  VEINS  TO 
THE   COMMON   ILIAC    ARTERIES. 


LIGATURE    OF   EXTERNAL    ILIAC    ARTERY. 


199 


verruilis  fascia  and  the  peritoncmn,  in  the  direction  of  the 
nuibilicus.  The  deep  circumflex  iliac  artery  comes  off  usually 
below  the  epigastric,  and  runs  outwards  behind  Poupart's 
ligament,  and  rests  upon  the  iliacus  muscle. 

The  external  iliac  vein  is  at  first  behind  the  artery,  and  a 
little  to  the  inner  side.  It  ultimately  is  found  upon  the  same 
plane  as  the  artery,  and 
entirely  to  the  imier  side 
(Fig.  56). 

The  internal  abdominal 
ring  is  situated  about  half 
an  inch  above  Poupart's 
ligament,  opposite  a  point 
midway  between  the  an- 
terior superior  spine  of  the 
ilium  and  the  sjmiphysis 
pubis. 

Line  of  the  Artery. — 
A  line  dra^vn  on  the  sur- 
face of  the  abdomen  from 
a  spot  about  a  finger's 
breadth  to  the  left  of  and 
below  the  navel,  to  a  j^oint 
midway  between  the  an- 
terior superior  iliac  spine 
and  the  symphysis  pubis. 
The  upper  third  of  this 
line  represents  the  com- 
mon ihac,  the  lower  two- 
thirds  the  external  iliac 
(Fig.  57). 

Indications.— The  ar- 
tery has  been  secured  in 
cases  of  wounds  and  of 
secondary       haemorrhage, 

and  for  the  treatment  of  aneurysms  in  the  upper  part  of  the 
thigh. 

It  has  been  ligatured  also  to  arrest  the  progress  of  malig- 
nant growths,  a2id  to  modify  the  condition  of  the  limb  in 
elephantiasis  ArabunL 


Fig.     ^7.  —  LIGATURE 
ARIEKY. 


OF      EXTERNAL       II.IAC 


Cooiier's  method  (moilified);  h,  AVjerrethy's 
method  (modified).  The  arrows  point  to  the 
anterior  superior  spines  and  the  spines  of 
the  pubes. 

LIGATURE   OF    COMMON    ILIAC   ARTERY. 

Mott's  method  (modified)  ;  d,  Marcelin 
Duval's  operation  ;  c.  Point  1^  inch  to  the 
outer  side  of  the  umbil'cus  ;  /',  Ligature  of 
internal  ihac  artery  (intraperitoneal  opera- 
tion). 


200  OPERATIVE    SURGERY. 

So  far  as  tlie  mortality  of  the  actual  operation  is  concerned^ 
the  procedure  may  be  regarded  as  a  successful  one,  169 
recorded  cases  having  given  in  all  but  61  deaths  (Lidell). 
The  vessel  was  ligatured  for  the  first  time  in  1796  by  Mr. 
Abernethy  for  inguinal  aneurysm.  His  first  two  cases  died, 
but  the  third  and  fourth  recovered.  (Medical  and  Physical 
Journal,  1802,  page  97  ;  and  "Surgical  Works,"  vol.  i.) 

Preparation  and  Position  of  the  Patient. — The  bowels 
should  have  been  well  evacuated,  and  if  there  be  much 
flatulent  distension  of  the  abdomen,  the  operation,  if  not 
urgent,  might  be  postponed  until  such  complication  has  been 
dealt  "with.     The  pubic  hair  should  be  shaved. 

The  patient  hes  upon  the  back,  with  the  thighs  extended 
and  close  together.  The  head  and  shoulders  should  be  raised 
in  order  to  relax  the  abdominal  parietes  a  little. 

The  surgeon  stands  to  the  outer  side  of  the  body  in 
dealing  with  either  artery,  and  cuts  from  above  downwards, 
on  the  right  side,  and  from  below  upwards  on  the  left.  His 
face  is  towards  the  patient's  face.  In  slender  subjects  the  left 
artery  might  be  quite  conveniently  tied,  as  the  operator  stands- 
to  the  right  of  the  patient's  body.  The  chief  assistant  is 
placed  opposite  to  the  surgeon,  and  to  him  is  entrusted  the 
responsible  office  of  using  the  retractor. 

A  good  broad  retractor  is  needed,  together  mth  long 
dissecting  forceps,  and  an  aneurj^sm  needle  with  a  lateral 
curve.  A  good  hght  is  essential.  A  reflector  "will  be  found 
convenient,  but  the  most  substantial  aid  is  afforded  by 
a  portable  electric  lamp — such  as  Trouv6's.  With  such  a 
lamp  as  this  the  main  difficulties  of  the  operation  are  re- 
moved. 

There  are  two  original  methods  of  exposing  the  artery,  both 
of  which  have  been  modified  beyond  recognition,  and  which 
are  known  as  Cooper's  operation  and  Abernethy's  method. 

1.  Sir  Astley  Cooper's  Operation. 

The  Original  Procedure. — "The  patient  being  placed  in 
the  recumbent  posture,  on  a  table  of  convenient  height, 
the  incision  is  to  be  begun  Avithin  an  inch  of  the  anterior 
superior  spinous  process  of  the  ilium,  and  is  extended  down- 
wards in  a  semicircular  direction  to  the  upper  edge  of  Pou- 
part's  ligament.      This  incision  exposes  the   tendon   of  the 


LIGATURE    OF   EXTERNAL    ILIAC    ARTERY. 


201 


external  oblique  muscle :  in  the  same  direction  the  above 
tendon  is  to  be  cut  through,  and  the  lower  edges  of  the 
internal  oblique  and  transversalis  abdominis  muscles  are 
exposed  ;  the  centre  of  these  muscles  is  then  to  be  raised  from 
Poupart's  ligament.  The  opening  by  which  the  spermatic  cord 
quits  the  abdomen  is  thus  exposed,  and  the  linger  passed 
through  this  space  is  directly  appHed  upon  the  ihac  artery, 
above  the  origin  of  the  epigastric  and  circumflexa  ilii  arteries. 
The  iliac  artery  is  placed  upon  the  outer  side  of  the  vein ;  the 
next  step  in  the 
opeiation     consists  a  ^ 

in  gently  separating 
the  vein  from  the 
artery  by  the  ex- 
tremity of  a  director, 
or  by  the  end  of 
the  linger.  The 
sohd  curved  an- 
eurysmal needle  is 
then  passed  under 
the  artery,  and  be- 
tween it  and  the 
vein  fi*om  without 
inwards,  carrying  a 
ligature ;  which 
being  brought  out 
at   the  wound,    the 

needle  is  withdrawn,  and  the  ligature   is   then   tied   around 
the  artery  as  in  the  operation  for  popliteal  aneurysm." 

The  Modified  Operation. — This  operation  has  been  modified 
in  very  many  ways,  and  with  such  modifications  various 
names  have  been  associated.  From  the  maze  of  these  pro- 
cedures the  following  may  be  selected  as  probably  best 
representing  the  modern  form  of  Cooper's  operation. 

The  position  of  the  patient  has  been  indicated.  An  incision 
three  and  a  half  inches  in  length  is  made  above  Poupart's 
Hgament.  The  cut  is  commenced  about  one  inch  and  a 
quarter  to  the  outer  side  of  the  spine  of  the  os  pubis,  and  is 
placed  three-eighths  of  an  inch  above  Poupart's  ligament. 
For  the  inner  two- thirds  of  its  length  it  runs  parallel  with  the 


Fig.  58.  —  LIGATURE  OP  RIRHT  EXTERNAL  ILIAC  ARTERY. 

(Modijied  Cooper'' s  method.) 

.V,  Aponeurosis  of  external  oblique ;  B,  Conjoined 
tendon  ;  c,  Internal  oblique  ;  D,  Line  of  incision  in 
int.  oblique  muscle  ;  a,  Position  of  ext.  iliac  artery  ; 
b,  Position  of  deep  epigastric  artery. 


202  OPERATIVE    SURGERY. 

ligament,  but  for  the  outer  ono-tliird  it  curves  a  little  upwards 
away  from  the  ligament.     (Fig.  57,  a.) 

The  skin  and  subcutaneous  tissues  are  cut  through,  and  in 
the  latter  will  be  divided  the  superficial  epigastric  artery 
and  vein. 

The  white,  glistening  aponeurosis  of  the  external  oblique 
muscle  is  now  ex230sed,  and  is  divided  in  the  Hue  of  the  skin 
incision.  The  knife  follows  very  nearly  the  direction  of  its 
fibres.  The  parts  being  retracted,  the  surgeon  now  seeks  for 
the  external  border  of  the  conjoined  tendon,  which  will  be 
made  out  at  the  inner  end  of  the  wound. 

The  lower  fibres  of  the  internal  oblique  muscle  are  dra^vn 
upwards  (Fig.  58),  and  are  divided  close  to  their  attachment  to 
Poupart's  ligament.  The  extent  of  the  division  corresjDonds 
to  the  extent  of  muscle  tissue  exposed  in  the  wound.  (The 
internal  oblique  is  attached  to  the  outer  half  or  two-thirds  of 
Pou^^art's  ligament,  the  transversalis  to  the  outer  third  only.) 

The  fascia  transversalis  is  now  exposed,  and  is  divided 
transversely  over  the  artery,  and  as  far  on  either  side  of  it  as 
is  necessary. 

At  this  stage  of  the  operation  care  must  be  taken  not  to 
wound  the  deep  epigastric  artery,  which  passes — between  the 
transversalis  fascia  and  the  peritoneum — across  the  wound 
area. 

The  external  iliac  artery  can  now  be  made  out.  The 
subperitoneal  tissue  about  the  vessels  should  be  gently 
loosened,  and  the  peritoneum  then  with  the  utmost  care  be 
peeled  from  the  artery  and  vein,  and  be  j)ushed  upwards  in 
the  direction  of  the  umbilicus  (Fig.  59). 

The  fingers  alone  should  be  emplo3^ed  in  this  process. 
Any  form  of  director  is  unnecessary  and  dangerous. 

The  artery  shoidd  be  bared  to  such  a  height  as  to  allow 
the  ligature  to  be  passed  around  it  at  a  point  one  inch  and 
a  quarter  above  Poupart's  ligament. 

The  peritoneum  must  be  kept  out  of  the  wa}^  Avith 
the  broad  retractor  while  the  artery  is  being  exposed. 

The  loose  subperitoneal  tissue  which  forms  a  kind  of 
sheath  for  the  artery  should  be  cautiousl}^  cleared  away. 

The  needle  is  passed  from  within  outwards. 

After  the  ligature  has  been  secured,  the  divided  fibres  of 


LIGATURE    OF   EXTERNAL    ILIAC    ARTERY. 


203 


the  internal  oblique  may  be  united  to  Poupart's  li^'ament,  and 
the  rent  in  the  external  oblique  aponeurosis  be  elosed  by  a 
few  points  of  catgut  suture. 

No  drainage-tube  is  required. 

Comment. — The  wound  must  be  of  sufficient  length,  and 
be  carefully  placed. 

If  it  be  made  too  low  down,  there  is  danger  of  dividir;- 
the  circumflex  iliac  vessels;  if  made  too  high  up,  of  cutti:^ 
into    the     internal 
abdominal  ring.     If  c, 

it  be  carried  too  far 
outwards,  an  un- 
necessary amount 
of  muscular  tissue 
is  diAdded ;  and  if 
too  far  inwards,  the 
external  ring  and 
the  structures  of  the 
cord  may  be  placed 
in  jeopardy. 

The  tissues  must 
be  cleanly  divided. 
The       transversalis 

Fis.  59. 


LIGATrKE  OF  RIGHr  EXTERNAL  ILIAC  ARTERY. 

fModiJii'd  Cooper''s  method.) 

A,  Aponeurosis  of  external  oblique ;  B,  Conjoined 
tendon  ;  c,  Internal  oblique  ;  D,  Transversalis  fascia  ; 
E,  Peritoneum  ;  a,  Ext.  iliac  art.  ;  h,  Ext.  iliac  vein  ; 
c,  Deep  epigastric  artery. 


fascia  should  be  cut 
sufficiently  high  to 
avoid  the  circumflex 
iliac  vein,  but  not 
at  too  great  a  height. 

"  I  made  the  incision,"  writes  Dr.  Sheen,  "  somewhat  too  high, 
and,  in  consequence,  opened  the  peritoneum,  which  I  mistook 
for  transversalis  fascia.  Even 'then  I  was  in  a  little  doubt, 
because  some  (omental)  fat  presented  itself,  which  very  much 
resembled  the  fat  .  .  .  seen  around  the  vessel ;  but  in 
pushing  this  up  gently,  a  knuckle  of  bowel  came  into  view, 
which  settled  the  matter." 

Care  should  be  taken  not  to  needlessly  tear  up  the  sub- 
peritoneal fatty  tissue,  and  infinite  care  must  be  taken  of  the 
peritoneum.  It  should  not  be  too  extensively  stripped  up, 
and  in  clearing  the  artery  with  the  finger  it  is  possible  to 
detach  the  vessel  from  the  psoas  muscle.     The  vein  has  been 


204  OPERATIVE    SURGEBY. 

damaged  in  passing  the  aneurysm  needle,  and  the  genito- 
crural  nerve  has  been  inchided  in  the  Hgature. 

The  peritoneum  has  been  not  mfrequently  opened.  This 
has  resulted  sometimes  from  too  hioii  an  incision,  because  the 
serous  membrane  becomes  more  and  more  intimately  con- 
nected with  the  transversalis  fascia  the  further  the  distance 
from  Poupart's  ligament.  The  peritoneal  cavity  has  also 
been  often  opened  up  by  the  incautious  use  of  the  steel  director 
(an  instrument  which  should  never  be  employed  in  this 
operation),  and  by  a  too  free  manipulation  with  the  handle  of 
the  scalpel. 

The  artery  should  be  secured  at  least  one  inch  and  a 
quarter  above  Poupart's  ligament,  in  order  that  the  ligature 
might  be  well  clear  of  the  large  branches  given  off  close  to 
the  ligament,  and  a  space  be  allowed  for  the  formation  of  the 
necessary  clot. 

The  deep  epigastric  artery  has  been  accidentally  cut 
during  the  operation. 

Without  strict  antiseptic  precautions  the  operation  carries 
with  it  the  risks  of  peritonitis,  and  of  diffuse  inflammation  of 
the  iliac  and  pelvic  connective  tissue. 

The  position  of  the  patient  should  be  as  described.  It  is 
inconvenient  to  relax  the  abdominal  parietes  by  flexing  the 
thighs  as  some  suggest. 

2.  Abernethy's  Operation. — Abernethy's  original  account 
is  as  follows  : — "  I  first  made  an  incision  about  three  inches  in 
length,  through  the  integuments  of  the  abdomen,  in  the 
direction  of  the  artery,  and  thus  laid  bare  the  aponeurosis  of 
the  external  obhque  muscle,  which  I  next  divided  from  its 
connection  with  Pouj)art's  ligament,  in  the  direction  of  the 
external  wound,  for  the  extent  of  about  two  inches.  The 
margin  of  the  internal  oblique  and  transversalis  muscles  being 
thus  exposed,  I  introduced  my  finger  beneath  them  for  the 
protection  of  the  peritoneum,  and  then  divided  them.  Next, 
with  my  hand,  I  pushed  the  peritoneum  and  its  contents 
upwards  and  inwards,  and  took  hold  of  the  external  iliac 
artery  with  my  finger  and  thumb.  ...  It  only  now 
remained  that  I  should  pass  a  ligature  round  the  artery  and 
tie  it."     ("Surgical  Works,"  vol.  i.,  page  254) 

Abernethy  later  thought  he  had  "disturbed  the  peritoneum 


LIGATURE    OF   EXTERNAL   ILIAG    ARTERY.         205 

too  much,  and  twd  the  artery  liigher  than  was  necessary." 
He  therefore  moditied  the  operation  to  the  extent  of  making 
the  incision  lower  down. 

What  was  known  as  Aberncthy's  operation  is  described  by 
fSouth  in  1847  ("CheHns'  Surgery")  in  this  manner.  The 
incision  was  four  inches  in  length,  and  was  commenced  one 
inch  and  a  half  above  and  to  the  inner  side  of  the  anterior 
superior  iliac  spine,  and  was  carried  down  in  the  direction  of 
the  external  iliac  artery,  to  a  point  half  an  inch  above  Pou- 
part's  ligament.  This  incision  is  shown  in  Fig.  57,  b.  The 
muscles  were  divided  in  order,  the  peritoneum  exposed  and 
pushed  back  in  the  manner  already  described. 

Co7)ir)ient  and  Gom-parison  of  the  two  Operations. — The 
comments  made  upon  the  previous  operation  apply,  with 
obvious  modifications,  to  the  present  method. 

Abernethy's  operation  enables  the  artery  to  be  ligatured 
higher  up,  and  the  incision  is  away  from  the  centre  of  the 
groin.  This  is  a  matter  of  consequence  in  dealing  with  a  case 
of  aneurysm  involving  the  upper  part  of  the  femoral  artery, 
and  possibly  encroaching  upon  Poupart's  ligament. 

The  wound,  moreover,  is  removed  from  the  abdominal 
rings,  and  does  not  concern  the  deep  epigastric  artery. 

Cooper's  operation,  however,  must  be  regarded  as  the 
better  of  the  two,  and  to  claim  that  position  upon  the  follow- 
ing grounds  : — The  operation  is  easier  to  perform.  The  peri- 
toneum is  dealt  with  at  a  spot  where  it  is  but  little  adherent. 
It  is,  in  consequence,  more  readily  displaced,  and  is  less 
exposed  to  damage. 

There  is  infinitely  less  division  of  the  muscular  structures 
of  the  abdominal  parietes,  the  wound  is  simpler,  and  the 
disposition  to  ventral  hernia  is  less. 

The  artery  is  exposed  at  a  great  depth  in  Abernethy's 
•operation,  and  the  wound  is  so  placed  that  the  passage  of  the 
aneurysm  needle  is  attended  with  great  difficulty,  and  with 
unusual  risk  of  wounding  the  vein. 

The  exposure  of  the  deep  epigastric  artery  would  appear  to  be 
no  objection  to  the  operation  advised.     It  is  easily  avoided. 

It  has  not  been  shown  that  any  special  evils  have  attended 
the  making  of  the  incision  close  to  the  openmgs  of  the 
inguinal  canal 


206  OPERATIVE    SURGERY. 

Abernetliy's  operation  can  be  recommended  wlien  the 
region  of  the  centre  of  the  groin  is,  for  one  reason  or 
another,  inacoessible,  or  unsuited  for  the  site  of  a  surgical 
incision,  and  also  in  a  case  in  which  it  is  considered  desiral)le 
to  ligature  the  vessel  as  high  up  as  possible. 

Collateral  Circulation  after  Ligature  of  the  External 
Iliac  Artery : 


Above. 

Below. 

Internal  mammary,  lumbarl 
and  lower  intercostal        J 

with 

Deep  epigastric. 

Lumbar  and  ilio-lurabar 

with 

Deep  circumflex  iliac. 

Obturator  and  sciatic 

with 

Internal  circumflex. 

Sciatic 

■with 

Superior  perforating. 

llluteal 

with 

External   and  internal  circumflex,  and 
first  perforating. 

Internal  pudic 

with 

External  pudic. 

For  the  varieties  of  the  artery  see  page  211. 

THE   COMMON    ILIAC   ARTERY. 

Anatomy. — The  common  iliac  artery  is  about  two  inches  m 
leno-th,  and  has  a  diameter  of  11  to  12  m.m.  The  right  vessel 
is  a  little  longer  and  usually  a  little  larger  than  the  left.  The 
aorta  bifurcates  opposite  to  the  centre  of  the  body  of  the  fourth 
lumbar  vertebra,  and  a  little  to  the  left  of  the  middle  line.  This 
point  corresponds  to  a  spot  about  three-quarters  of  an  inch 
beloAV,  and  just  to  the  left  of  the  umbilicus,  and  is  on  a 
level  with  a  line  drawn  transversely  between  the  highest  part;i 
of  the  two  iliac  crests. 

The  conmion  iliac  bifurcates  opposite  to  the  lumbo-sacra] 
articulation. 

The  vessel  is  covered  by  peritoneum,  and  has  running 
over  it  many  sympathetic  nerve  fibres  on  their  way  to  the 
hypogastric  plexus.  The  ureter  runs  athwart  the  vessel  near 
its  bifurcation. 

The  left  vessel  lies  close  to  the  bodies  of  the  fourth  and 
fifth  lumbar  vertebrae,  and  alongside  of  the  psoas  muscle. 
The  artery  on  the  right  side  is  separated  from  the  psoas  and 
the  vertebne  by  the  two  common  iliac  veins. 

The  relation  of  the  veins  to  the  arteries  is  shown  in  Fig. 
56.     It  will  bo  seen  that  the  vena  cava  and  both  coinmon 


LIGATURE    OF    COMMON   ILIAC    ARTERY.  207 

iliac  veins  are  in  close  connection  with  the  right  common 
artery. 

The  vessels  tend  to  become  tortuous  in  old  age. 

The  Live  of  the  Artery  has  already  been  given  (page  199). 

Indications. — There  are  very  few  circumstances  under 
which  ligature  of  this  vessel  may  be  considered  justifiable. 

It  has  been  secured  in  cases  of  wound  of  the  artery,  and  in 
haemorrhage  from  the  external  or  internal  iliac,  or  from  the 
branches  of  the  latter  trunk. 

It  has  been  ligatured  for  the  relief  of  aneurysm  of  the 
external  or  internal  iHac,  and  as  a  preliminary  to  the  removal 
of  large  vascular  growths. 

The  vessel  was  tirst  tied  in  1812  by  Professor  W.  Gibson, 
of  Philadelphia  {Aine7\  Med.  and  Surg.  Recorder,  vol.  iii.,  page 
185),  for  gunshot  wound  of  the  artery.  The  peritoneal  cavity 
was  opened  up.     The  patient  died  on  the  thirteenth  day. 

Dr.  Mott,  of  New  York  (Amer.  Jour,  of  Med.  Sciences,. 
vol.  i.,  page  156),  carried  out  the  first  extra-peritoneal  operation 
in  1827,  for  aneurysm  of  the  internal  iliac  artery.  The  patient 
did  well.  The  mortality  of  the  operation  has  been  very  high. 
Lidell  reports  only  sixteen  recoveries  in  sixty-eight  recorded 
cases.  The  very  great  majority  of  these  operations  took  place 
before  the  introduction  of  antiseptic  surgery,  and  some  of  the 
patients  died  of  causes  which  are  no  longer  unpreventable. 

The  recent  tendencies  of  abdominal  surgery  render  it 
probable  that  in  the  future  the  artery  will  be  reached  by  a 
simple  incision  into  the  peritoneal  cavity  through  the  anterior 
abdominal  parietes.  {See  Ligature  of  the  Internal  Iliac 
Artery  and  page  211.) 

1.  Ligature  of  the  Artery  through  an  Anterior  Incision. 
— The  preparation  and  position  of  the  patient  are  the  same  as 
have  been  already  described  in  dealing  with  the  external  iliac 
artery  (page  200). 

In  stripping  off  the  peritoneum  the  patient  should  be 
turned  a  little  upon  the  sound  side,  in  order  that  the  intestines 
may  be  carried  away  from  the  wound  area. 

The  incision  on  the  right  side  may  be  made  from  above 
downwards,  and  on  the  left  from  below  upwards. 

A  good  light  is  required.  Broad  spatuke  or  retractors  are 
needed,  and  the  surgeon  should  have  provided  himself  with 


208  OPERATIVE    SVBGERY. 

that  form  of  aneurysm  needle  which  practice  of  the  operation 
upon  the  dead  body  has  shown  him  to  be  the  most  convenient. 
A  large,  long  needle  with  a  lateral  curve  {see  page  102  of 
Introduction)  will  probably  be  found  the  most  convenient. 

(a)  Motfs  Operation. — An  mcision  from  five  to  eight 
inches  in  length  is  commenced  just  outside  the  centre  of 
Poupart's  ligament,  and  one  inch  and  a  half  above  it. 

It  then  curves  upwards  and  outwards  in  the  direction  of 
the  ribs,  passing  the  crest  of  the  ilium  one  inch  and  a  half 
in  front  (i.e.,  to  the  inner  side)  of  the  anterior  superior  spinous 
process.     {See  Fig.  57,  c.) 

The  skin  and  subcutaneous  tissues  are  divided,  and  the 
aponeurosis  of  the  external  oblique  is  exposed,  together  with 
— in  the  upper  part  of  the  incision — a  portion  of  the  muscle 
itself  Both  aponeurosis  and  muscular  fibres  are  divided  in 
the  line  of  the  original  incision.  The  internal  oblique  muscle 
is  now  reached,  and  is  cut  through  in  the  same  manner. 

The  transversalis  muscle  is  in  turn  exposed,  and  its  fibres 
are  severed  from  one  end  of  the  wound  to  the  other. 

Between  the  two  last-named  muscles  will  be  met  the 
ilio-hypogastric,  ilio-inguinal,  and  last  dorsal  nerves,  and 
probably  the  ascending  branch  of  the  deep  circumflex  iliac 
.artery.  If  the  incision  be  carried  high  up,  other  dorsal 
(intercostal)  nerves  are  met  with. 

The  transversalis  fascia  is  well  exposed,  and  is  divided 
along  the  whole  length  of  the  Avound. 

The  peritoneum  is  now  very  carefully  stripped  from  the 
iUac  fascia,  and  the  external  iliac  artery  sought  for.  The 
serous  membrane  is  pushed  aside  in  the  manner  already 
described  (page  202),  until  the  common  iUac  trunk  is  reached. 
The  ureter  is  pushed  aside  {i.e.,  upwards  and  inwards)  with 
the  peritoneum. 

The  coat  of  the  artery  is  well  exposed,  and  the  needle 
should  be  passed,  on  either  side  of  the  body,  from  right 
to  left. 

There  is  considerable  risk  of  injuring  the  vein.  The 
lio-ature  should  be  applied,  if  possible,  to  the  middle  of  the 
artery. 

(b)  Marcellin  Duval's  Operation. — The  mcision  is  about 

five  inches  in  lengtlL    It  is  commenced  one  inch  and  a  quarter 


LIGATURE    OF    COMMON   ILIAC    ARTERY.  209 

to  the  outer  side  of  the  spine  of  the  piibes,  a  little  above 
Poiipart's  ligament.  The  tirst  inch  and.  a  half  of  the  incision 
is  parallel  with  Poujjart's  ligament.  The  incision  is  now 
sharply  curved  upwards,  and  ultimately  follows  a  line  which 
is  perpendicular  to  the  ligament,  and  is  directed  towards  a 
point  one  inch  and  a  quarter  to  the  outer  side  of  the 
umbilicus.     {See  Fig.  57,  d.) 

The  three  abdominal  muscles  are  divided,  together  with 
the  transversalis  fascia,  and  the  artery  is  reached  by  pushing 
aside  the  peritoneum  in  the  manner  already  described. 

Comiuent. — The  general  observations  made  upon  the 
operation  for  ligaturing  the  external  iliac  artery  (page  203) 
apply  equally  to  this  procedure.  There  is  great  danger  of 
wounding  the  peritoneum.  A  very  efficient  retraction  of  the 
soft  parts  is  essential,  and  the  passing  of  the  needle  is 
associated  with  considerable  difficulty. 

Mott  himself  made  an  incision  five  inches  long,  beginning 
immediately  above  the  external  abdominal  ring,  and  continued 
in  a  semilunar  direction  half  an  inch  above  Poupart's  liga- 
ment to  a  little  above  the  anterior  superior  iliac  spine.  This 
incision  was  too  low  down. 

The  operation  described  is  easy,  so  far  as  the  exposure  and 
separation  of  the  peritoneum  is  concerned ;  but  the  vessel  is 
reached  at  a  great  depth,  and  the  passing  of  the  needle  is 
attended  with  considerable  difficulty. 

Duval's  procedure  would  appear  to  be  the  best  of  the 
anterior  extra-peritoneal  operations.  The  artery  is  well  and. 
easUy  exposed.  The  wound,  however,  in  the  abdominal  muscles 
is  of  considerable  extent,  and  the  conditions  favourable  for 
ventral  hernia  are  somewhat  increased.  Duval's  incision  is 
convenient  also  for  ligature  of  the  internal  iliac  artery. 

2.  Ligature  of  the  Artery  through  a  Lateral  Incision. — 
This  operation  was  lirst  carried  out  by  Sir  P.  Crampton,  and 
is  des(;ribed  by  him  in  the  following  words  (Med.-Chir.  Trans., 
vol.  xvi.,page  161).  The  loin  is  well  exposed,  the  patient  lying 
upon  the  sound  side.  "  The  first  incision  commenced  at  the 
anterior  extremity  of  the  last  false  rib,  proceeding  directly 
downwards  to  the  ilium.  It  then  followed  the  line  of  the 
crista  ilii,  keeping  a  very  little  within  its  inner  margin,  until  it 
terminated  at  the  superior  anterior  spinous  proc-ess  of  that 


210  OPERATIVE    SUBGEHY. 

bone.  The  incision  was  therefore  chiefly  curvilinear,  the  con- 
cavity looking  towards  the  navel.  The  abdominal  muscles 
were  then  divided  to  the  extent  of  about  an  inch,  close  to  the 
superior  anterior  spinous  process,  down  to  the  peritoneum 
Into  this  wound  the  forefinger  of  the  left  hand  was  introduced, 
and  passed  slowly  and  cautiously  along  the  line  of  the  crista 
ilii,  separating  the  peritoneum  from  the  fascia  iliaca.  A 
probe-pointed  bistoury  was  now  passed  along  the  finger  to  its 
extremity ;  and  by  raising  the  heel  of  the  knife,  while  its  point 
rested  firmly  at  the  end  of  the  finger,  as  on  a  fulcrum,  the 
abdominal  muscles  were  separated  from  their  attachments  to 
the  crista  ilii  by  a  single  stroke. 

"  By  repeating  this  manoeuvre  the  wound  was  prolonged 
until  sufficient  room  was  obtained  to  pass  down  the  hand 
between  the  peritoneum  and  the  fascia  iliaca.  Detaching  the 
very  sHght  connection  which  these  parts  have  with  each  other, 
I  was  able  to  raise  up  the  peritoneal  sac  with  its  contained 
mtestines  on  the  palm  of  my  hand,  from  the  psoas  magnus 
and  iliacus  internus  muscles,  and  thus  obtain  a  distinct  view 
of  all  the  important  parts  beneath,  and,  assuredly,  a  more 
striking  view  has  seldom  been  presented  to  the  eye  of  the 
surgeon.  The  parts  were  unobscured  by  a  single  drop  of 
blood ;  there  lay  the  great  iliac  artery,  nearly  as  large  as  my 
finger,  beating  a^vfully  at  the  rate  of  two  in  a  second,  its 
yellowish-white  coat  contrasting  strongly  with  the  dark  blue 
of  the  iliac  vein,  which  lay  beside  it,  and  seemed  nearly  double 
its  size.  The  ureter,  in  its  course  to  the  bladder,  lay  like  a 
white  tape  across  the  artery,  but  in  the  process  of  separating 
the  peritoneum  it  was  raised  from  it  with  that  membrane, 
to  which  it  remained  attached.  .  .  .  Nothing  could  be 
more  easy  than  to  pass  a  ligature  round  an  artery  so  situated. 
The  forefinger  of  the  left  hand  was  passed  under  the  artery, 
which,  with  a  little  management,  was  easily  separated  from 
the  vein ;  and  on  the  finger  (which  served  as  a  guide)  a  com- 
mon eyed-probe,  furnished  with  a  ligature  of  moistened  catgut, 
was  passed  under  the  vessel." 

Comment — Compared  with  Mott's  operation,  this  pro- 
cedure has  certain  decided  advantages.  The  actual  operation 
is  much  easier ;  the  peritoneum  is  less  disturbed,  and  is  more 
readily  separated :  the  artery  is  brought  actually  into  view, 


LIGATURE    OF    COMMON   ILIAC    ARTERY.  211 

and  the  ligature  is  passed  with  compai-ative  ease :  there  is  a 
less  probability  of  the  formation  of  a  ventral  hernia:  and, 
lastly,  the  wound  affords  better  conditions  for  efficient  drain- 
age. Between  Crampton's  operation  and  that  of  Marcellin 
Duval  there  is  a  less  conspicuous  comparison.  In  both,  the  • 
artery  is  well  and  admirably  exposed.  In  stout  and  muscular 
subjects  the  lateral  wound  may  have  to  be  carried  to  a  great 
depth ;  but,  on  the  other  hand,  it  is  in  a  position  in  which  the 
probabilities  of  a  ventral  hernia  are  decidedly  less  than  in  the 
anterior  operation. 

3.  The  Intra-Peritoneal  Operation. — This  method  would 
be  carried  out  upon  the  lines  indicated  in  the  account  of  the 
Ligature  of  the  internal  iliac  artery.     {See  page  213.) 

The  same  median  incision  in  the  abdominal  wall  might  be 
employed. 

The  operation  is  simple,  and  is  without  complication,  and 
of  the  various  methods  of  securing  the  vessel  it  may  probably 
be  considered  to  be  the  best,  although  the  procedure  has  yet 
to  be  tested. 

I  am  not  aware  that  the  operation  has  been  carried  out 
upon  the  living  subject. 

Collateral  Circulation  after  Ligature  of  the  Common 
Iliac  Artery. — 

Above.  Below, 

Internal   mammary  and  lower  j  ^.^^  j^^^p  epigastric. 

intercostals  > 

Lumbar  with  Deep  circumflex  iliac  and  iUo-lumbar. 

Superior  haemorrhoidal  with  Hsemorrhoidal  branches  of    internal 

iliac. 

Middle  sacral  with  Lateral  sacral. 

Pudic,  epigastric,  obturator,  and  \          fh  ( '^^'^   corresponding  vessels  on  the 

visceral  arteries                          )  I  opposite  side. 

Varieties  of  the  Iliac  Arteries. — 

1.  The  aorta  may  bifurcate  a  little  below,  or,  in  rarer 

instances,  a  little  above  the  normal  situation. 

2.  The  common  iliac  arteries  may  bifurcate  above  or 

below  the  point  indicated,  and  may  vary  in  length 
between  one  inch  and  a  half  and  three  inches. 

3.  The  deep  epigastric  artery  may  arise  from  the  ex- 

ternal iliac,  one  and  a  half,  or  even  two  and  a  half 
o  2 


212  OPERATIVE    SURGERY. 

inches  above  Poiipart's  ligament.  The  deep  cir- 
ciimllex  artery  may  arise  as  high  as  one  inch 
above  the  hgament. 
4.  The  internal  iliac  artery  may  vary  in  size  from  half 
an  inch  to  three  inches,  and  its  place  of  division 
may  be  at  any  point  between  the  upper  margin  of 
the  sacrum  and  the  upper  border  of  the  sacro- 
sciatic  foramen. 

The  Internal  Iliac  Artery  (II.). 

Anatomy. — This  vessel,  which  measures  from  one  to  one 
inch  and  a  half  in  length,  extends  from  the  bifurcation  of 
the  common  iliac  to  the  upper  margin  of  the  great  sacro-sciatic 
notch,  where  it  breaks  up  into  its  ultimate  branches. 

It  lies  at  first  near  the  inner  edge  of  the  psoas  muscle,  and 
then  upon  the  sacrum  and  lumbo-sacral  cord.  It  is  covered 
by  peritoneum,  and  is  crossed  by  the  ureter  at  its  commence- 
ment. The  vein  lies  behind  and  somewhat  to  the  inner  side 
(Fig.  56).  The  varieties  of  the  artery  have  been  already 
detailed  (page  211). 

Indications. — The  circumstances  under  which  this  opera- 
tion is  justifiable  are  very  few.  It  has  been  ligatured  for 
haemorrhage,  but  with  very  unsatisfactory  results.  Lidell 
states  that  out  of  twenty-seven  recorded  examples  of  the- 
operation,  only  eight  recoveries  can  be  claimed.  The  great 
majority  of  the  successful  cases  are  instances  of  ligature  for 
the  cure  of  gluteal  aneurysm. 

The  operation  was  first  performed  with  success  by  Dr.  W. 
Stevens,  of  Santa  Cruz,  in  1812,  for  aneurysm  {Med.-Chir. 
Trans.,  vol.  v.,  page  422).  He  made  an  incision  five  inches  in, 
length  through  the  anterior  abdominal  parietes,  parallel  with 
the  deep  epigastric  artery,  and  about  half  an  inch  to  the 
outer  side  of  it.  The  peritoneum  was  pushed  aside,  and  the 
artery  reached  as  in  the  operation  for  the  ligature  of  the 
common  iliac. 

1.  The  Extra-Peritoneal  Operation. — The  incision  em- 
ployed is  the  same  as  that  made  to  secure  the  common  iliac 
artery,  the  procedure  of  Marccllin  Duval  being  the  best  suited 
for  the  purpose  (page  208). 

The  preparation  of  the  patient,  the  position  assumed,  and 


LIGATURE    OF   INTERNAL   ILIAC    ARTERY.  213 

the  general  features  and  special  danglers  of  the  operations  for 
securing  the  iliac  arteries,  have  already  been  dealt  with  in  the 
sections  on  the  common  iliac  and  the  external  iliac. 

In  the  present  case  the  peritoneum  is  pushed  aside,  until 
the  external  iliac  is  reached.  The  surgeon  is  guided  to  the 
internal  artery  by  following  the  more  superficial  trunk.  The 
upper  margin  of  the  great  sacro-sciatic  notch  is  easily  identi- 
fied, and  will  serve  to  indicate  the  lower  end  of  the  artery. 
The  passing  of  the  ligature  is  difficult,  and  many  aneurysm 
needles,  of  various  sizes,  and  with  various  curves,  should  be  at 
hand.  The  needle  should  be  passed,  on  either  side  of  the 
body,  from  within  out. 

2.  The  Intra-Peritoneal  Operation. — This  procedure  has 
been  advocated  by  Dr.  Dennis,  of  New  York  (JSfeiv  York  Med. 
News,  November,  1886).  He  reports  three  cases,  in  all  of 
which  the  ligature  was  applied  for  aneurysm.  In  one  case  the 
right  internal  iliac  was  secured,  and  in  another  the  left.  Both 
patients  were  cured.  In  the  third  instance,  both  internal 
iliacs  were  ligatured.  The  patient,  a  woman  of  sixty,  died  on 
the  third  day.  I  ligatured  the  artery  with  success  in  a  boy 
aged  sixteen,  for  a  vascular  tumour  of  the  buttock,  in  Novem- 
ber, 1889,  by  this  method. 

Operation. — The  abdomen  is  opened  in  the  middle  line 
by  an  incision  extending  from  the  symphysis  pubis  to  the 
umbilicus,  or  to  a  point  a  little  above  it  (Fig.  57,  /).  The 
intestines  having  been  pushed  up  and  drawn  aside,  the  area  of 
the  deep  wound  is  surrounded  by  sponges,  and  so  cut  off  from 
the  peritoneal  cavity.  I  employed  six  sponges  in  this  way,  and 
had  the  wound  well  opened,  and  the  sponges  kept  in  position 
by  two  large  metal  retractors  and  one  ivoiy  spatula. 

The  peritoneum  over  the  artery  is  thus  well  exposed,  and 
is  divided  to  the  extent  of  one  inch  and  a  half.  The  artery 
is  followed  down  from  the  bifurcation  of  the  common  iliac. 
The  vein  will  appear  to  be  about  three  times  the  size  of  the 
artery,  and  the  separation  of  the  two  is  a  matter  of  some 
delicacy.  Care  should  be  taken  that  the  ureter  is  not  damaged 
nor  accidentally  included  in  the  ligature.  The  many  sympa- 
thetic nerve  fibres  which  follow  the  artery  may  be  avoided  if 
the  coat  of  the  vessel  be  well  exposed. 

A  good  light,  several  broad  retractors   or   spatulas,  long 


214  OPERATIVE   SURGERY. 

dissecting  forceps,  and  a  variety  of"  aneurysm  needles,  are  re- 
quired. Tlie  operation  should  be  performed  with  the  care 
which  is  essential  in  every  abdominal  section. 

Gomment. — The  advantages  of  this  method  are  obvious. 
The  vessel  is  easily  and  fully  exposed,  and  the  needle  can  be 
passed  without  risk  to  the  vein  or  the  ureter.  The  operation  is 
simple,  and  involves  but  little  time.  Its  dangers  are,  com- 
paratively speaking,  very  few.  The  ligature  can  be  applied 
accurately  at  the  spot  determined  upon.  The  condition  of  the 
artery  and  of  the  surrounding  parts  can  be  made  out,  and 
a  diagnosis  confirmed  or  modified.  The  great  objection  that 
some  few  years  ago  would  have  been  urged  against  the  pro- 
cedure— the  risk  of  acute  peritonitis — may  be  at  the  present 
day  almost  disregarded. 

Collateral  Circulation  after  Ligature  of  the  Internal 
Iliac  Artery : 


Above. 

Seloio. 

Middle  sacral 

■with 

Lateral  sacral. 

Inferior  mesenteric 

with 

Hfemorrhoidal  arteries. 

Bi-anches  of  profunda  femoris 

with 

Sciatic  and  gluteal. 

Circumflex  iliac 

with 

Ilio-liimbar. 

Internal  pudic  and  oTjturator  with         the  vessels  of  the  opposite  side. 

BRANCHES   OF   THE   INTERNAL   ILIAC   ARTERY. 

1.— The  Gluteal  Artery  (III.). 

Anatomy. — This,  the  largest  branch  of  the  internal  iliac 
artery,  turns  round  the  upper  margin  of  the  great  sacro- 
sciatic  foramen,  and  divides  opposite  the  interval  between  the 
gluteus  medius  and  pyriformis,  into  two  divisions,  a  super- 
ficial and  a  deep.  The  former  passes  backwards  between  the 
gluteus  medius  and  pyriformis,  and  reaches  the  great  gluteus. 

The  latter  runs  forwards  between  the  gluteus  medius  and 
gluteus  minimus. 

The  vein  lies  anterior  to  the  trunk  of  the  artery,  and  the 
superior  gluteal  nerve  is  placed  a  little  below  it. 

Line  of  the  Artery. — If  a  line  be  drawn  from  the  pos- 
terior superior  iliac  spine  to  the  top  of  the  great  trochanter, 
when  the  thigh  is  rotated  in,  a  point  at  the  junction  of  the 
upper  with  the  middle  third  of  that  line  will  correspond  to 


LIGATURE    OF   GLUTEAL   ARTERY. 


215 


the  point   at   which   the  gluteal   artery   emerges   from    the 
sciatic  notch  (Fig.  60,  A,  b). 

Indications. — This  operation  can  very  rarely  be  called  for. 
It  has  been  performed  with  success  in  cases  of  stab  wound,  in 
a  case  of  haemo- 
rrhage following  the 
evacuation  of  a 
gluteal  abscess,  and 
in  certain  examples 
of  false  aneurysm. 

It  was  first  liga- 
tured by  John  Bell 
in  1808  for  false 
aneurysm  ("  Princi- 
ples of  Surgery"). 

Operation.- — The 
patient  is  rolled 
nearly  over  on  to 
the  face;  the  limb 


IS 


allowed  to  hang 


over  the  edge  of  the 
table;  the  thigh  is 
rotated  in.  The 
surgeon  stands  upon 
the  side  to  be  dealt 
with. 

An  incision  five 
inches  in  length  is 
made  along  the  line 


-THE    INCISIONS    FOR  THE   GLUTE.\L,    SCTATICt 
OR   PUDIC   ARTERIES. 


A,  Post.  sup.  iliac  spine ;  B,  Great  trochanter ;  c,  Tuber 
ischii ;  u.  Ant.  sup.  Iliac  spine ;  .\-B,  Gluteal  line ; 
A-c,  Sciatic  and  pudic  line  (MacCormac). 


just  given.  The 
centre  of  the  inci- 
sion should  corre- 
spond to  the  point  of  exit  of  the  artery  (Fig.  60). 

After  dividing  the  skin  and  superficial  fascia  with  a  few 
cutaneous  nerves,  the  gluteus  maximus  is  reached,  covered  byits 
fascia.     The  incision  runs  parallel  with  the  fibres  of  the  muscle. 

These  fibres  are  separated  in  the  hue  of  the  wound  until 
the  thickness  of  the  muscle  has  been  traversed.  A  muscular 
branch — from  the  superficial  division  of  the  artery — may  here 
be  met  with,  and  will  form  a  guide  to  the  trunk. 


216  OPERATIVE    SURGERY. 

The  deep  fascia  between  the  gkitei  muscles  is  reached,  and 
the  contiguous  margins  of  the  ghiteus  medius  and  pyriformis 
muscles  are  exposed. 

The  gluteus  maximus  is  now  relaxed  by  placing  the  fully 
extended  thigh  upon  the  table.  The  interval  between  the 
gluteus  medius  and  pyriformis  is  opened  up  with  retractors, 
and  the  upper  margin  of  the  sciatic  notch  defined.  The  super- 
ficial division  of  the  artery  passes  between  the  two  muscles, 
and  leads  the  operator's  finger  to  the  main  trunk.  The  ligature 
should  be  applied  as  far  within  the  notch  as  possible — almost 
within  the  pelvis, — inasmuch  as  the  artery  breaks  up  into  its 
two  divisions  as  soon  as  it  has  cleared  the  notch 

Care  must  be  taken  to  include  neither  the  nerve  nor  the 
vein.  In  order  to  obtain  a  fuller  view  of  the  vessel,  some 
fibres  of  the  great  sacro-sciatic  hgament  may  require  to  be 
divided. 

2. — The  Sciatic  or  Internal  Pndic  Arteries  (IV.). 

The  hgature  of  these  vessels  has  scarcely  ever  been  called 
for  in  actual  practice.  The  operation  has  been  performed  for 
some  uncommon  examples  of  wound. 

Anatomy. — The  sciatic  and  pudic  arteries  descend  to- 
gether in  front  of  the  pyriformis  muscle,  and  leave  the  pelvis 
by  the  lower  part  of  the  great  sacro-sciatic  foramen.  The 
sciatic  continues  its  course  downwards  under  cover  of  the 
gluteus  maximus,  and  rests  upon  the  obturator  internus 
and  gemelh  muscles. 

The  pudic  curves  forward  over  the  ischial  spine,  and 
enters  the  pelvis  again  by  the  small  sacro-sciatic  foramen. 

At  the  lower  margin  of  the  pyriformis  muscle  the  sciatic 
artery  is  superficial  to  the  pudic,  and  passes  behind  it  to 
gain  its  outer  side.  Both  vessels  are  accompanied  by  vense 
comites.  To  the  inner  side  of  the  pudic  artery,  at  the  lower 
border  of  the  pyriformis,  he  the  internal  pudic  nerve  and  its 
inferior  htemorrhoidal  branch. 

The  sciatic  artery,  near  the  same  place,  is  superficial  (i.e., 
posterior)  to  both  the  small  and  the  great  sciatic  nerves. 

Operation. — The  point  at  which  the  sciatic  and  pudic 
arteries  emerge  from  the  pelvis  and  reach  the  gluteal  region 
is  indicated  by  a  line  drawn  (when  the  thigh  is  rotated  in) 
from  the  posterior  superior  iliac  spine  to  the  outer  part  of  the 


LIGATURE    OF   ABDOMINAL    AORTA.  217 

tuber  ischii  (Fig.  60,  A — c).  The  point  in  question  is  at  the 
junction  of  the  middle  with  the  lower  third  of  this  line. 

An  incision,  some  four  inches  in  length,  is  made  obliquely 
across  this  hue  in  the  direction  of  the  tibres  of  the  gluteus 
maximus,  and  is  so  placed  that  its  centre  corresponds  to  the 
point  just  indicated  (Fig.  60). 

The  gluteus  maximus  is  divided  in  the  line  of  the  wound, 
and  the  lower  margin  of  the  jjyriformis  muscle  and  the  spine 
of  the  ischium  are  well  defined. 

The  ligature  should  be  passed  as  near  to  the  pelvis  as 
possible. 

THE   ABDOMINAL   AORTA. 

So  far  as  the  present  history  of  this  operation  is  con- 
cerned, the  ligation  of  the  abdominal  aorta  can  scarcely  be 
considered  to  be  a  justifiable  procedure. 

It  has  been  resorted  to  in  severe  cases  of  iliac  and 
ing-uinal  aneurysm  which  have  resisted  all  other  modes  of 
treatment,  and  has  been  practised  for  the  arrest  of  both 
primary  and  secondary  haemorrhage. 

The  aorta  was  first  ligatured  by  Sir  Astley  Cooper  in  1817 
("Prin.  and  Prac.  of  Surgery,"  vol.  i.,  page  228),  by  opening 
up  the  abdominal  cavity  in  the  median  line. 

The  second  operation  was  performed  by  James,  of  Exeter, 
in  1827  (Med.-Chir.  Trans.,  vol.  xvi.,  page  10).  He  followed 
the  procedure  of  Cooper.  His  patient  lived  a  few  hours  only. 
Cooper's  patient  survived  the  operation  forty  hours. 

The  third  operation  was  carried  out  by  Murray,  at  the  Cape 
of  Good  Hope,  in  1834  (Lond.  Med.  Gaz.,  vol.  xiv.,  page  68). 
He  reached  the  artery  by  a  lateral  incision,  and  did  not  open 
the  peritoneal  cavity.     The  patient  died  in  twenty-four  hours. 

The  fourth  and — in  certain  respects — the  most  important 
case  was  in  the  charge  of  Monteiro,  at  Rio  Janeiro.  He  ligatured 
the  aorta  in  1842  by  the  extra-peritoneal  method,  using  the 
incision  employed  by  Murray.  The  patient  Hved  ten  days, 
and  died  of  secondary  haemorrhage  (Schmidt's  Jahrbucher, 
1843). 

Since  then  the  operation  has  been  performed  by  South, 
Hunter,  McGuire,  Stokes,  "Watson,  Czerny  of  Vienna,  and 
Czerny  of  Heidelberg. 

There  are  eleven  cases  in  all,  and  all  eleven  patients  died 


218  OPERATIVE    SURGERY. 

Avithin  a  comparatively  short  time  of  the  operation.  The 
most  successful  case  was  that  of  Monteiro,  whose  patient 
hved  ten  days. 

As  the  majority  of  these  operations  were  carried  out  before 
the  introduction  of  antiseptic  methods  in  surgery,  and  before 
the  recent  improvements  in  Ugature  material  had  been 
effected,  it  may  reasonably  be  argued  that  they  do  not  form 
an  argument  for  the  absolute  abandonment  of  the  operation. 

Cooper's  patient  appears  to  have  died  of  acute  peritonitis, 
a  comphcation  that  may,  with  some  certainty,  be  avoided  at 
the  present  day. 

Monteiro's  patient  might  possibly  have  escaped  death  from 
secondar}^  haemorrhage  had  the  operation  been  performed  anti- 
septically,  and  had  a  more  suitable  Hgature  been  employed. 

This  case  alone  would  appear  to  sanction  the  Hgature  of 
the  aorta  in  desperate  cases  of  ihac  or  inguinal  aneurysm, 
when  every  other  mode  of  treatment  had  failed. 

It  must  not  be  forgotten,  however,  that  when  a  spon- 
taneous aneurysm  involves  one  or  other  of  the  ihac  arteries, 
it  cannot  be  expected  that  the  walls  of  the  aorta  itself  will  be 
free  from  disease. 

Anatomy. — The  point  of  bifurcation  of  the  aorta  has  been 
already  described  (page  206).  The  vessel  at  its  lower  part  is 
covered  by  the  peritoneum  only,  and  upon  the  front  of  the 
artery,  and  beneath  the  serous  membrane  at  this  point,  are 
the  important  sympathetic  nerve  cords,  which  pass  from  the 
aortic  to  the  hypogastric  plexus.  The  aortic  plexus  lies  along 
the  aorta,  between  the  origins  of  the  superior  and  inferior 
mesenteric  arteries.  The  hypogastric  plexus  lies  in  the 
interval  between  the  two  ccjmmon  iliac  arteries.  Much 
areolar  tissue  surrounds  the  vessel,  and  the  vena  cava  lies  to 
its  right  side.  The  inferior  mesenteric  artery  arises  between 
one  and  tsvo  inches  above  the  bifurcation  of  the  aorta,  and 
it  is  between  this  vessel  and  the  origin  of  the  common  iliacs 
that  the  ligature  should  be  ap])licd. 

1.  The  Intra-Peritoneal  Operation  (Astley  Cooper). — The 
patient  hes  upon  the  back,  with  the  shoulders  raised.  An 
incision,  three  to  four  inches  in  length,  is  made  in  the  linea 
alba,  the  centre  of  the  incision  corresponding  to  the  umbiHcus. 
The  peritoneal  cavity  is  opened,  and  the  intestines  having 


LIGATURE    OF   ABDOMINAL   AORTA.  219 

been  drawn  aside,  tlie  serous  membrane  covering  the  vessel 
is  neatly  divided.  The  artery  should  then  be  well  bared  mid- 
way between  the  bifurcation  and  the  origin  of  the  inferior 
mesenteric  artery,  as  it  is  of  primary  importance  that  none 
of  the  sympathetic  nerve  fibres  should  be  included  in  the 
ligature.  The  great  vessel  is  best  isolated  with  the  finger. 
The  needle  must  be  passed  from  right  to  left,  and  care  must 
be  taken  not  to  damage  the  vena  cava.  A  stout  piece  of 
chromicised  catgut  of  large  size  will  be  required.  The 
operation  needs  a  good  light,  a  reflector  or  an  electric  lamp, 
broad  spatulee,  and  an  especially  long  aneurysm  needle,  with 
such  a  curve  as  the  operator's  own  experiments  upon  the 
cadaver  have  shown  to  bo  the  most  convenient. 

2.  The  Extra-Peritoneal  Operation  (Murray). — This  ope- 
ration involves  a  very  deep  and  complicated  wound.  The 
vessel  is  reached  with  difficulty,  and  the  passing  of  the  needle 
is  attended  with  considerable  danger.  The  procedure  would 
not  have  been  described  had  it  not  been  the  method  which 
was  carried  out  in  the  most  successful  of  the  eleven  cases — 
viz.,  in  Monteiro's  case. 

A  curved  incision — with  the  concavity  forwards — mea- 
suring about  six  inches,  is  made  upon  the  left  side  of  the 
body,  from  the  extremity  of  the  tenth  rib  to  a  point  about 
one  inch  to  the  inner  side  of  the  anterior  superior  iliac  spine. 
The  three  abdominal  muscles  and  the  transversalis  fascia  are 
divided  in  the  manner  already  described  in  the  operation 
for  ligaturing  the  common  iliac  artery.  The  peritoneum  is 
separated  from  the  iliac  fascia;  the  common  iliac  trunk  is 
in  this  way  reached,  and  the  surgeon's  fingers  are  gradually 
led  to  the  aorta  itself.  The  vessel  should  be  isolated  as  well 
as  is  possible  by  the  finger.  It  should  be  bared  of  the  areolar 
tissue  around  it,  in  order  to  avoid  the  inclusion  in  the  lio^ature 
of  the  sympathetic  nerve  trunks. 

The  needle  is  passed  from  left  to  right,  the  vein  being 
protected  by  the  forefinger. 


part  lY. 
OPERATIONS    UPON    NERVES. 

CHAPTER      I. 

Introductory. 

The  following  are  the  operations  which  are  considered  in 
this  connection. 

1.  Nerve  stretching. 

2.  Neurotomy,  or  section  of  a  nerve  trunk. 

3.  Neurectomy,   or   excision   of  a  portion   of  a  nerve 

trunk. 

4.  Neuroraphy,  or  suture  of  a  divided  nerve  trunk. 
These  operations  are  all  of  comparatively  modem  origin. 

The  good  effect  of  nerve  stretching  upon  irregular  muscular 
contractions  was  observed  by  Nussbaum  in  1860  in  a  case  in 
which  the  ulnar  nerve  was  accidentally  stretched  during  an 
excision  of  the  elbow.  Billroth  met  with  a  similar  accidental 
experience  in  1S69.  In  1872  Nussbaum  practised  the  hrst 
intentional  nerve  stretching. 

With  the  appearance  of  Vogt's  monograph  in  1877  con- 
spicuous attention  was  drawn  to  the  subject,  and  a  few  years 
later  the  operation  was  introduced  into  England. 

Neurotomy  for  neuralgia  and  more  especially  for  neuralo-ias 
of  the  face,  is  not  a  very  modern  operation.  It  was  practised 
by  Marechal  in  the  middle  of  the  18th  century,  and  in  1798 
John  Haighton  published  an  account  of  "  a  case  of  tic  doulou- 
reux or  painful  affection  of  the  face,  successfully  treated  by  a 
division  of  the  affected  (infra-orbital)  nerve."  Subsequent  to 
this  the  operation  appears  to  have  been  so  frequently  and  so 
recklessly  employed  that  the  procedure  sank  into  disrepute. 
It  was  revived  again  about  1852  by  Roux  and  others,  and  was 
placed  upon  a  more  sound  basis. 

The  suture  of  nerves  has  for  centuries  attracted  the  notice 


222  OPERATIVE    SURGERY. 

of  surgfeons,  but  the  matter  received  little  but  theoretical 
treatment.  In  1776  Cruikshank  established  the  reality  of  the 
cicatrisation  of  nerves,  and  the  work  of  Weir  Mitchell  upon 
gunshot  injuries  of  nerves,  published  in  1864,  drew  notable 
attention  to  the  clinical  features  of  certain  nerve  lesions.  In 
the  same  year,  Laugier  and  Nelaton  performed  what  was 
probably  the  fii'st  definite  and  well-planned  neuroraphy. 
They  were  certainly  the  tirst  to  give  a  precise  account  of  the 
operation. 

1.  Nerve  Stretching. — This  procedure  has  been  applied  to 
nerves  of  all  kinds,  both  large  and  small,  to  motor  and  sensory 
nerves,  as  well  as  to  those  of  mixed  composition.  During  the 
period  at  which  a  rage  for  nerve  stretching  existed  even  the 
optic  nerve  was  stretched  in  cases  of  loss  of  vision  (Wecker 
1881,  Parnard  1882). 

The  measure  has  been  employed  in  the  treatment  of 
various  forms  of  muscular  spasm  (e.g.,  wry  neck,  tic  convulsif, 
tetanus),  in  peripheral  neuralgias,  in  peripheral  neuritis,  in 
sciatica,  in  reflex  epilepsy,  in  cases  of  hyperiesthesia,  painful 
ulcer  and  painful  stump,  and  for  the  relief  of  anaesthesia  in 
leprosy,  and  lightnmg  pains  in  locomotor  ataxy.  The  results 
have,  on  the  whole,  not  been  very  satisfactory.  The  best 
effects  have  been  obtained  in  certain  cases  of  sciatica  and 
of  peripheral  neuritis,  in  a  proportion  of  the  examples  of 
neuralgia,  and  in  instances  of  spasmodic  contraction  of 
muscles. 

The  extensibility  of  nerves  varies  greatly,  and  is  influenced 
by  the  size  and  situation  of  the  trunk,  its  condition,  the  age 
and  general  state  of  the  patient. 

It  is  said  that  a  weight  of  about  6  lb.  10  oz,  is  required 
to  extend  the  median  nerve  of  an  adult  man  three-fourths 
of  an  inch,  and  that  the  elasticity  of  the  nerve  is  such,  that  it 
will  return  to  its  normal  length  when  the  extending  force  is 
removed,  even  when  the  tension  has  been  maintained  for  a 
few  hours. 

Nerve  trunks  are  more  extensile  near  the  spinal  cord  than 
at  a  distance,  and  in  the  upper  than  in  the  lower  limb.  This 
depends  probably  upon  the  strength  of  the  nerve  sheath, 
which  is  subject  to  variation,  and  against  which  the  main 
strain  of  the  stretching  is  directed. 


NERVE    STRETCHING.  223 

Modus  Operandi. — The  nerve  is  exposed  at  its  most  con- 
venient and  usually  at  its  most  superficial  part,  and  is  then 
clearly  isolated  and  brought  well  into  view. 

In  the  limbs  the  joints  may  be  so  flexed  as  to  relax  the 
parts  about  the  site  of  the  operation.  Good  retractors  will 
usually  be  required.  The  larger  nerve  trunks  are  stretched 
by  means  of  the  finger  and  thumb,  smaller  nerves  by  means 
of  a  suitable  blunt  hook,  and  the  smallest  cords  by  the  aid  of 
a  probe  or  director. 

"  The  nerve,"  writes  Mr.  Horsley,  "  being  firmly  held  be- 
tween the  finger  and  thumb,  is  then  to  be  steadily  pulled  for 
about  five  minutes,  first  centrifugally,  and  then  centripetall}^ 
for  a  like  period  of  time.  The  tension  must  be  gradually 
applied  and  kept  constant  the  whole  time,  while  all  jerks 
(the  force  of  which  is  unknown)  are  to  be  avoided.  The 
actual  amount  of  force  with  which  it  is  advisable  to  pull, 
varies  from  a  maximum  of  thirty  pounds  for  the  sciatic  nerve, 
to  half  a  pound  for  the  supra- trochlear.  The  amount  of  force 
must  necessarily  vary  with  individual  development  and  the 
state  of  the  nerve  (Marshall).  It  will  now  be  found  that  the 
nerve  is  loose  and  elongated,  owing  to  its  elasticity  being 
relatively  very  imperfect."  With  regard  to  the  sciatic  nerve 
Marshall  writes,  "  If  I  first  pull  as  hard  as  I  imagine  I  should 
do  upon  a  living  sciatic  nerve  during  an  operation,  I  find  that 
the  force  employed  is  about  equal  to  twenty  pounds  ;  but  if  I 
pull  very  hard,  it  is  increased  to  thirty  pounds  ;  and  that,  I 
believe,  is  as  hard  as  a  surgeon  could  well  pull  when  holding 
a  soft  nerve  between  his  finger  and  thumb." 

The  nerve  having  been  replaced,  the  incision  is  closed. 

The  part  should  be  kept  absolutely  at  rest  until  the  wound 
has  entirely  healed.  Active  and  passive  movements  of  the 
limb  should  then  be  gradually  carried  out,  and  some  form  of 
simple  massage  be  employed. 

2  and  3.  Neurotomy  and  Neurectomy. — These  operations 
have  been  adopted  in  the  treatment  of  similar  cases  to  those 
mentioned  in  the  previous  paragraph.  They  are  of  necessity 
limited  to  smaller  nerves,  and  in  nearly  ever}'  instance  to  such 
nerves  as  are  purely  sensory. 

In  cases  of  peripheral  neuralgia,  and  in  certain  painful 
affections  —  such  as  cancer  of   the  tongue  —  neurotomy  or 


224  OPERATIVE    SURGERY. 

neurectomy  lias  met  with  a  certain  amount  of  success.  In  the 
neuralgic  cases  there  is  a  great  disposition  to  relapse  after  a 
varying  period.  The  patients  are  often  not  the  best  subjects 
for  operation  ;  many  are  hysterical,  and  in  not  a  few  possibly 
the  diagnosis  has  been  ill-considered  and  the  time  ill-selected. 

The  nerve  is  exposed  at  some  "  place  of  election,"  and  is 
dealt  with  by  one  or  other  of  the  methods  named. 

The  majority  of  these  operations  are  not  of  great  gravity. 

4.  Neuroraphy. — This  o^Deration  concerns  the  union  of 
nerve  trunks  which  have  been  severed  by  accident. 

The  term  "  immediate  suture  "  is  applied  to  cases  in  which 
the  divided  ends  of  the  nerve  are  united  within  a  short  time 

of  the  accident ;  the  term  "  secondary 

h^  suture "    to   instances    in   which    a 

Fig.  61.-H00KDSEDIN  NEUE-     pei'iod  of  timc  varying  from  weeks 

oTOMT     OE     NEUEECTOMY,     to  mouths  has  elapscd  between  the 

(Xatural  size.)  .  „     ,        .    .    -^  , 

receipt  oi  the  mjury  and  the  opera- 
tion. It  is  needless  to  say  that  the  former  measure  is  the 
simpler  and  by  far  the  more  successful. 

In  the  immediate  suture,  the  wound  is  perfectly  cleaned, 
the  cut  ends  of  the  nerve  are  brought  together  and  united  by 
sutures.  Any  bruised  or  jagged  part  of  the  exposed  nerve  is 
cut  away.  The  general  features  of  the  operation  are  identical 
with  those  now  to  be  described. 

In  the  secondary  suture  the  steps  of  the  procedure  are  as 
follow : — 

1.  The  nerve  is  exposed.  The  incision  is  made  over  the 
course  of  the  nerve,  and  parallel  to  it.  This  part  of  the 
operation  may  be  complicated  by  the  presence  of  much 
cicatricial  tissue  and  many  adhesions,  by  wasting  of  adjacent 
muscles,  by  deformity,  by  the  existence  of  a  mass  of  callus 
about  a  fracture,  and  by  much  retraction  of  the  nerve  itself. 
In  most  instances  the  use  of  an  Esmarch's  tourniquet  is  not 
to  be  advised.  Even  in  a  case  of  simple  division  of  the  nerve 
by  a  stab,  an  interval  of  from  a  half  to  one  inch  may  be  found 
to  separate  the  divided  ends.  In  instances  where  there  has 
been  much  destruction,  the  interval  may  be  greater. 

The  upper  end  of  the  nerve  is  more  easily  found  than  the 
lower.     It  is  usually  enlarged,  bulbous,  and  sensitive. 

The  lower  end,  on  the  other  hand,  is  usually  atrophied  and 


NEURORAPHY.  225 

filiform,  and  is  apt  to  be  lost  in  cicatricial  tissue,  and  to  be  free 
from  notable  sensation. 

It  may  be  necessary  to  expose  the  trunk  of"  the  nerve 
lower  doAvn  and  then  to  follow  the  cord  upwards,  in  order  to 
find  the  "  lower  end  "  with  greater  certainty. 

In  any  case  the  operator  must  be  prepared  to  make  a  very 
free  wound. 

Each  portion  of  the  exposed  nerve  should  be  freed  for 
some  distance  respectively  upwards  and  downwards,  and  the 
ends  carefully  drawn  up  in  order  to  bring  as  much  of  the 
nerve  as  possible  into  the  wound  area  to  overcome  the  gap 
resulting  from  retraction,  and  to  allow  the  extremities  to  be 
brought  readily  in  contact. 

2.  The  two  exposed  ends  are  excised.  This  is  best  done 
with  sharp  small  scissors.  The  cut  must  be  clean  and  quite 
transverse.  The  bulb  may  be  cut  away  layer  by  layer  until  a 
section  of  healthy  nerve  tibres  is  exposed.  It  is  not  always 
necessary  to  remove  the  whole  of  the  bulbous  end.  Indeed, 
the  firmer  tissues  of  the  bulb  afford  an  excellent  hold  for  the 
sutures.  Bowlby  advises  that  the  section  should  j)ass  through 
the  upper  end  of  the  bulb,  close  to  the  trunk. 

"With  regard  to  the  lower  end  of  the  nerve,  Bowlby  advises 
that  it  is  only  necessary  "  to  cut  away  the  extreme  end,  which, 
being  matted  with  fibrous  tissue  and  compressed  by  the 
surrounding  scar,  is  very  likely  to  contain  no  nerve  tubules. 
It  is  seldom  necessary  to  remove  as  much  as  j  inch,  and 
however  unhealthy  the  section  may  look,  no  good  is  ever  to 
be  gained  by  a  further  sacrifice." 

3.  The  two  ends  are  united  by  sutures.  From  2  to  6  or 
8  sutures  will  be  required,  according  to  the  size  of  the  divided 
nerve.  The  material  should  be  either  fine  silk  or  chromicised 
catgut  or  the  finest  silkworm  gut.  Some  surgeons  especially 
recommend  kangaroo  tendon  sutures.  The  thread  is  passed 
by  means  of  a  Hagedorn's  curved  needle.  A  small  "  intestinal " 
needle  answers  admirably.  The  needle  should  be  introduced 
about  i  of  an  inch  from  the  free  end  of  the  nerve,  and  the 
thread  should  be  carried  through  the  Avhole  thickness  of  the 
trunk.  If  the  sheath  be  substantial  or  use  can  be  made  of  the 
cicatricial  tissue  around  the  nerve,  the  sutures  may  be  intro- 
duced into   the   extra-neural  structures.      Sutures,  however, 

1' 


226  OPERATIVE    SURGERY. 

which  are  limited  to  the  sheath  are  of  very  little  use.  No 
harm  has  been  shown  to  follow  the  passing  of  the  needle 
through  the  substance  of  the  nerve.  If  six  sutures  are  to  be 
applied,  three  may  involve  the  nervous  cord  and  three  the 
sheath,  or  connective  tissue  dissected  up  with  it.  The  ends  must 
be  brought  into  close  contact  and  be  very  accurately  adjusted. 

All  rough  handling  of  the  nerve  must  be  avoided. 

4,  The  wound  is  closed.  No  drainage  tube  is  required,  and 
every  care  should  be  taken  to  ensure  the  healing  of  the  wound 
by  first  intention.  The  limb  should  be  so  adjusted  that  the 
parts  concerned  in  the  operation  wound  are  relaxed,  and  no 
traction  is  brought  to  bear  upon  the  sutured  nerve.  For 
example,  if  the  nerve  concerned  be  the  median  in  the  forearm, 
both  the  elbow  and  the  wrist  joints  should  be  flexed.  The 
parts  must  be  rigidly  maintained  in  the  desired  position  by 
means  of  splints,  and  should  be  well  protected  and  kept  warm. 

As  soon  as  the  wound  has  soundly  healed,  passive  move- 
ments, together  with  massage  and  galvanism,  may  be  cautiously 
employed. 

Tke  result  of  neuroraphy  must  depend  upon  many  circum- 
stances— upon  the  nature  of  the  injury,  the  lapse  of  time  since 
the  nerve  was  divided,  the  amount  of  separation  of  the  two 
ends,  the  local  condition,  the  state  of  the  patient's  health,  the 
amount  of  degeneration  which  has  taken  place,  and  the  readi- 
ness with  which  the  operation  wound  has  healed.  In  any 
case  it  must  be  remembered  that  a  very  considerable  time 
must  be  allowed  to  elapse  before  the  surgeon  can  form  an 
opinion  as  to  the  final  results  of  the  operation.  Complete 
restoration  of  function  will  often  require  one  or  two  years,  and 
no  improvement  of  any  kind  may  be  evident  for  several 
months  after  the  neuroraphy. 

Subjoined  is  an  account  of  the  mMkods  of  exposing  the 
nerves  most  usually  subjected  to  operation.  Comparatively 
few  nerves  are  dealt  with,  and  no  attempt  has  been  made  to 
give  a  description  of  aU  the  operations  which  have  been,  or 
may  be  performed.  There  are  few  of  the  superficial  nerves 
of  the  body  which  have  not  been  cut  down  upon  at  one  time 
or  another.  In  the  limbs  many  of  the  nerves  are  exposed 
through  the  incision  required  for  the  ligature  of  the  companion 
artery,  as  for  exainplo  the  anterior  or  posterior  tibiul. 


227 


CHAPTER    II. 

Operations  upon  the  Nerves  of  the  Head  and  Neck. 

'the  first  division  of  the  trifacial  nerve. 

The  Supra  -  Orbital  Nerve.  —  Anatomy.  —  This  nerve 
escapes  through  the  supra-orbital  notch  and  ascends  vertically 
upwards.  The  notch  is  situated  at  the  junction  of  the  middle 
with  the  inner  third  of  the  upper  orbital  margin.  At  this 
spot  the  nerve  lies  beneath  the  orbicularis  palpebrarum,  and 
is  usually  found  to  have  already  broken  up  into  two  divisions. 
It  is  accompanied  by  the  supra-orbital  vessels  which  he  to  its 
outer  side  (Figs.  62  and  63). 

Operation. — The  eyebrow  is  steadied  by  the  operator's 
left  hand  Avhile  an  assistant  draws  the  eyelid  downwards. 
An  incision  about  three-quarters  of  an  inch  in  length  is  made 
horizontally  along  the  superior  orbital  margin  in  such  a  way 
that  its  centre  will  correspond  to  the  supra-orbital  notch. 
The  integuments  and  orbicularis  muscle  having  been  cut 
through,  the  nerve  is  readily  exposed.  The  vessels  should  be 
avoided. 

Comment. — A  vertical  incision  exposes  more  of  the  nerve, 
and  is  simpler,  but  it  makes  a  more  considerable  section  of  the 
muscle  and  leaves  a  larger  scar. 

the  second  division  of  the  trifacial  nerve. 

Anatomy. — The  superior  maxillary  nerve  pursues  a  nearly 
horizontal  course  from  the  foramen  rotundum  to  the  infi*a- 
orbital  foramen  on  the  anterior  surface  of  the  upper  jaw.  If 
the  course  of  the  nerve  be  followed  the  distance  between  these 
two  foramina  is,  in  the  adult  skull,  about  two  inches. 

At  the  infra-orbital  foramen  the  nerve  breaks  up  into  its 
ultimate  cutaneous  branches,  viz.,  the  palpebral,  labial,  and 
nasal  (Figs.  62  and  63). 

A  little  beyond  the  foramen  rotundum  the  nerve  crosses  the 
p  'I 


228 


OPERATIVE    SUliGEBY. 


splieno-maxillary  fossa,  and  at  the  spot  where  it  bridges  over 
this  fossa,  Meckel's  ganglion  is  found; 

The  distance  from  the  infra-orbital  foramen  (on  the 
face)  to  Meckel's  ganglion  can  seldom  be  less  than  If  inch. 

The  following  is  the  guide  for  the  infra-orbital  foramen.  A 
line   is    draAvn    downward    from   the    supra-orbital  foramen 


Fig.  62.— THE  NERVES  OF  THE  PACE  AND  THEIR  RELATIONS  TO  THE  ARTERIES  OF 

THE  REGION.     {From  Meckel.) 


(page  227)  so  as  to  cross  the  gap  between  the  two  bicuspids 
in  both  jaws.  This  line  will  cross  both  the  infra-orbital  and 
the  mental  foramina.  The  former  is  just  above  the  canine 
fossa  and  about  a  (piarter  of  an  inch  below  the  margin  of  the 
orbit. 

Meckel's  ganglion  is  a  triangular  body  with  a  diameter 
of  about  one-fifth  of  an  inch.  It  is  surrounded  by  the 
terminal  branches  of  the   internal  maxillary  artery,  and  has 


INFRA-ORBITAL    NERVE.  229 

the  following  relations.  Above  it  is  the  superior  maxillary 
nerve,  behind  it  are  the  sphenoid  bone  and  the  vidian  canal, 
on  its  outer  side  are  the  termination  of  the  internal  maxillary 
artery  and  the  external  pterygoid  muscle,  and  on  its  inner 
side  are  the  vertical  plate  of  the  palate  bone  and  the  spheno- 
palatine foramen. 

As  this  nerve  is  often  dealt  with  in  the  treatment  of 
neuralgia  involving  the  upper  teeth,  the  position  of  its  branches 
is  important.  Within  the  skull  it  gives  off  the  recurrent 
branch  to  the  dura  mater.  Between  the  foramen  rotundum 
and  the  oransflion  comes  off  the  orbital  branch.  Between  the 
ganglion  and  the  superior  maxilla,  i.e.,  at  the  point  of  entrance 
into  the  infra-orbital  canal,  arises  the  posterior  dental  branch 
which  supplies  the  molars.  At  the  hinder  part  of  the  canal 
and  within  the  maxilla  takes  origin  the  middle  dental  nerve 
which  supplies  the  bicuspid  and  canine  teeth.  The  incisor 
teeth  are  supplied  b}^  the  anterior  dental  nerve  which  arises 
at  the  anterior  part  of  the  canal  close  to  the  iiifra-orbital 
foramen. 

In  order  therefore  that  all  the  dental  nerves  might  be 
severed,  the  nerve  trunk  must  be  divided  as  far  back  as 
Meckel's  ganglion. 

The  posterior  half  of  the  infra-orbital  canal  is  open  to  the 
orbit,  and  exists  as  a  groove  merely,  the  anterior  half  has  a 
bony  roof  and  takes  therefore  the  form  of  a  genuine  osseous 
canal.  Occasionally  the  whole  or  part  of  the  posterior  portion 
of  the  so-called  canal  has  a  bony  roof,  and  in  such  case  no  part 
of  the  nerve  could  be  exposed  from  the  orbit  without  cutting 
through  a  thin  plate  of  bone. 

The  infra-orbital  vessels  which  accompany  the  nerve  in  the 
infra-orbital  canal  are  small  and  have  an  inconstant  relation  to 
the  nerve,  although  they  more  usually  lie  to  its  outer  side. 
In  one  instance  I  found  the  artery  winding  around  the  nerve. 

1.  The  Infra-Orbital  Nerve.  —  Operation.  —  This  nerve 
may  be  exposed  as  it  leaves  the  infra-orbital  foramen  by 
means  of  a  transverse  incision  three-quarters  of  an  inch  in 
length  made  about  a  quarter  of  an  inch  below  the  lower 
margin  of  the  orbit,  and  so  placed  as  to  cross  the  infra-orbital 
foramen  (Figs.  62  and  63). 

After  the  skin,  layer  of  subcutaneous  fat,  and  orbicularis 


230  OFEEATIVE    SURGERY. 

iniiscle  have  been  divided,  the  levator  labii  superioris  is 
exposed  and  must  be  severed  in  the  Une  of  the  original  wound. 
The  nerve  is  now  reached  and  can  be  dealt  with.  The  parts 
are  vascular  and  the  view  of  the  nerve  is  apt  to  be  occluded  by 
free  bleeding. 

Gorriment. — Section  of  the  nerve  at  this  spot  cuts  off 
merely  the  terminal  branches  to  the  face.  Subcutaneous 
division  of  the  nerve  through  the  mouth  has  been  advised,  but 
experience  has  shown  that  in  the  treatment  of  neuralgia 
mere  division  of  the  terminal  fibres  of  a  nerve  is  of  little 
service. 

Various  methods  have  been  devised  for  deaUng  with 
the  infra-orbital  nerve  nearer  to  its  commencement  by  ex- 
posmg  it  through  the  floor  of  the  orbit. 

An  incision  is  made  along  or  near  the  lower  margin  of  the 
orbit,  the  orbital  fascia  is  divided  and  the  contents  of  the 
cavity  are  displaced  upwards  by  means  of  a  thin  spatula. 

The  infra-orbital  groove  is  exposed  and  the  nerve  divided 
as  far  back  as  possible.  If  the  terminal  part  has  been  brought 
into  view  through  the  skin  incision,  a  considerable  part  of  the 
nerve  might  be  drawn  out  after  the  division. 

These  operations  are  unsatisfactory.  The  wound  is  very 
deep  and  the  area  of  the  operation  is  exceedingly  narrow. 
The  orbital  tissues  are  disturbed  and  the  globe  and  its 
nerve  apparatus  are  exposed  to  danger.  Moreover,  unless  the 
nerve  be  divided  as  far  back  as  the  commencement  of  the 
infra-orbital  groove  only  the  anterior  dental  nerve  will  be  re- 
moved by  the  neurectomy.  Severe  haimorrhage  into  the  orbit 
and  exomphalos  have  followed  these  measures.  The  state- 
ment that  the  nerve  has  been  divided  as  far  back  as  the 
spheno-maxillary  fossa  when  exposed  through  the  orbital 
floor  may  be  open  to  some  question. 

2.  The  Trunk  of  the  Superior  Maxillary  Nerve  and 
Meckel's  Ganglion. 

in  some  forms  of  intractable  neuralgia  the  nerve  has  been 
divided  on  the  distal  side  of  the  foramen  rotundum  and  the 
whole  triuik  removed  as  far  forwards  as  the  infra-orbital  fora- 
men, together  with  Meckel's  ganglion. 

Operation. — A  -shaped  incision  is  made  on  the  front  of 
the  cheek  so  placed  that  the  apex  points  directly  downwards 


MECKEL'S    GANGLION.  231 

and  the  centre  of  the  V  is  opposite  to  the  infra-orbital 
foramen.  The  incision  should  form  two  sides  of  an  equi- 
lateral triangle,  each  limb  of  which  measures  a  little  more 
than  one  inch  (Fig.  65,  b). 

The  knife  is  carried  at  once  down  to  the  bone,  and  the  tri- 
angular flap  formed  by  the  soft  parts  is  turned  up  over  the 
lower  lid.  A  long  silk  suture  is  introduced  into  the  apex  of 
the  flap,  in  order  that  it  may  be  drawn  well  upwards  out  of 
the  surgeon's  way. 

The  infra-orbital  nerve  is  sought  for  and  isolated  as  it  is 
emerging  from  the  foramen.  The  bone  having  been  cleared,  a 
portion  of  the  anterior  wall  of  the  antrum  measuring  from 
I  to  J  of  an  inch  square  is  removed  with  a  chisel  and  mallet. 
The  infra-orbital  foramen  will  be  a  little  above  the  centre  of 
the  part  removed.  The  mucous  lining  of  the  antrum  having 
been  divided  that  cavity  is  fully  opened.  In  order  that  the 
rest  of  the  operation  may  be  conveniently  performed,  a  small 
electric  lamp  is  needed  which  may  be  fixed  to  the  surgeon's 
forehead.     In  no  operation  is  a  good  light  more  essential. 

The  posterior  wall  of  the  antrum  is  now  exposed,  and  a 
portion  about  ^  of  an  inch  square  is  cut  away  with  a  fine 
chisel  and  mallet. 

In  removing  the  two  portions  of  bone  some  surgeons  use 
trephines — a  half-inch  trephine  for  the  anterior  wall  and  a 
quarter-inch  for  the  posterior.  The  chisel  is,  however,  by  far 
the  more  convenient  and  precise  instrument,  and  inflicts  a  less 
degree  of  injury  upon  the  surrounding  tissues. 

The  haemorrhage  is  very  free,  and  some  little  time  may 
now  be  devoted  to  arresting  it  as  far  as  is  possible. 

The  next  step  consists  in  dividing  the  mucous  lining  on  the 
roof  of  the  antrum,  under  the  course  of  the  infra-orbital  canal. 
The  bone  forming  the  floor  of  this  canal  must  be  broken  away 
from  one  end  of  the  maxilla  to  the  other.  This  is  best  effected 
by  means  of  scissors,  aided  by  a  fine  carpenter's  bradawl  and  a 
slender  bone  elevator  or  stout  director.  The  bone  is  thin  and 
offers  little  resistance,  and  the  nerve,  which  must  be  most  care- 
fully preserved  and  carefully  followed  line  by  line,  forms  the 
guide  to  the  surgeon's  movements.  Much  bleeding  may  be 
expected  from  the  damaged  infi-a-orbital  vessels,  Avhich  can 
seldom  be  surely  isolated.     When  the  posterior  wall  of  the 


232  OPERATIVE    SURGERY. 

maxilla  is  reached,  the  white  and  conspicuous  nerve  will  bo 
hanging  loose  in  the  cavity  of  the  antrum.  Slender  dissecting 
forceps  Avith  long  blades  are  needed  during  this  stage,  and 
become  still  more  necessary  when  the  region  of  the  foramen 
rotundum  is  reached. 

The  bone  of  the  hinder  wall  of  the  antrum  must  be  so 
completely  removed  that  the  nerve  is  seen  to  hang  free  in  the 
cavity  produced.  The  wound  may  now  be  stuffed  for  a  while 
with  a  conical  piece  of  sponge  in  order  that  the  hemorrhage, 
which  is  still  free,  might  be  held  a  little  in  check. 

By  means  of  the  long  slender  forceps  and  a  director  the 
surgeon  endeavours  to  make  out  the  position  of  the  trunk  as 
it  issues  from  the  foramen  rotundum,  and,  if  possible,  the  pre- 
cise locality  of  the  ganglion.  In  this  attempt  he  is  aided  by 
the  infra-orbital  nerve  upon  which  traction  (by  means  of  a  silk 
thread)  is  maintained.  Finally  the  superior  maxillary  nerve 
is  divided  close  to  the  foramen  rotundum  by  a  pair  of  very 
slender  curved  scissors,  and  any  branches  which  still  hold  the 
nerve  in  position  having  been  divided,  the  whole  trunk  is  re- 
moved with  the  ganglion  attached. 

At  this  step  of  the  operation  also  much  bleeding  may  be 
expected.  The  nerve  cord  removed  should  measure  not  less 
than  one  inch  and  three-quarters. 

The  antrum  having  been  sponged  out  the  skin  incision  is 
united  by  sutures  and  the  selected  dressing  applied.  A  small 
drainage  tube  should  be  maintained  in  the  lower  angle  of  the 
wound  for  the  first  twenty- four  hours. 

Comment — The  operation  above  described  is  a  modification 
of  the  procedure  introduced  by  Carnochan  of  New  York, 
{Amer.  Journ.  Med.  8c.,  1858,  page  136)  who  appears  to  have 
been  the  first  surgeon  to  have  excised  the  superior  maxillary 
nerve.  An  excellent  account  of  "  neurectomy  of  the  second 
division  of  the  fifth  nerve  "  is  given  by  Chavasse  in  the  Medico- 
Ghirurgical  Trwi abactions  for  1884.  Chavasse  has  collected 
twenty-two  examples  of  Carnochan's  operation.  In  three  only 
of  these  does  the  relief  appear  to  have  been  permanent.  In 
most,  if  not  in  all  of  the  cases,  a  trephine  was  used. 

I  have  performed  the  operation  five  times  during  the  last 
ten  years.  In  all,  the  wound  healed  well  and  soundly.  In 
one  instance  facial  erysipelas  developed,  but  with  this  exception 


MECKEL'S    GANGLION.  233 

the  operation  was  followed  by  little  or  no  constitutional  dis- 
turbance The  deformity  produced  was  quite  insignificant,  and 
the  scar  was  by  no  means  conspicuous.  In  the  tAvo  severest 
cases  the  neuralgia  returned  at  the  end  of  three  years  and  two 
years  respectively.  One  patient  died  of  cancer  six  months 
after  the  operation.  In  the  remaining  two  patients  the  pain 
returned  within  twelve  months.  In  one  of  these  I  was  not 
sure  that  I  had  succeeded  in  removing  the  ganglion. 

Other  Methods  of  F  erf  arming  this  Operation  are  described 
by  Chavasse  in  the  following  words : — 

Professor  Liicke,  of  Strasburg,  makes  an  oval  incision  "  from 
a  point  just  above  the  external  canthus  of  the  eye,  passing  at 
first  backwards,  then  downwards  and  forwards,  and  termin- 
ating at  the  zygomatic  process  of  the  upper  jaw.  The  masseter 
muscle  is  divided  and  the  zygomatic  arch  sawn  through  an- 
teriorly, and  fractured  posteriorly.  This  piece  of  bone,  with 
the  temporal  fascia  attached  to  it,  is  turned  upwards.  By 
these  means  the  spheno-maxillary  fossa  is  reached,  and  the 
nerve  is  cut  as  it  emerges  from  the  skull.  The  fractured  bone 
is  then  replaced  and  the  masseter  muscle  attached  to  it  with 

sutures.     Union  of  the  bone  shortly  takes  place 

The  drawback  to  it  is  the  contraction  of  the  muscle  which  is 
apt  to  follow,  leading  to  depressed  cicatrices,  and  thus  necessi- 
tating prolonged  after-treatment. 

"  To  obviate  this  difficulty  Professor  Lossen,  of  Heidelberg, 
has  modified  the  operation  by  dividing  the  temporal  fascia 
along  the  upper  edge  of  the  zygoma,  then,  after  fracturing 
the  bone,  turning  it  backwards  with  the  masseter  left  intact. 
After  replacement  of  the  bone,  the  temporal  fascia  is  stitched 
in  its  old  position,  and  the  masseter  is  unable  to  draw  the 

bony  fragment  downwards Reyher  operated  by 

first  tying  the  common  carotid  artery  and  then  cutting  away 
the  nerve,  according  to  the  plan  of  Lossen.  Nussbaum  and 
Bilh-oth  have  also  cut  away  portions  of  the  superior  maxillary 
nerve  by  means  of  Langenbeck's  osteo-plastic  resection  of  the 
upper  jawbone,  and,  still  more  recently,  Gerster  has  advocated 
a  modification  of  this  procedure  by  sawing  through  the  middle 
of  the  malar  bone." 

These  various  measures  are  all  needlessly  seve  Hjid 
involve  wounds  of  great  and  unnecessary  magnitude 


234  OPERATIVE   SURGERY. 

Since  it  is  to  be  questioned  whether  this  neurectomy  is  of 


Fig.  63. — THE  NERVES  OF  THE  FACE  AND  OF  THE  SIDE  OF  THE  HEAD. 

{From  Meckel.) 

permanent  value  the  operations  last  described  can  hardly  be 
considered  to  be  justified  by  the  results  obtained. 

THE   THIRD   DIVISION   OF    THE   TRIFACIAL   NERVE. 

1.  The  Trunk  of  the  Nerve  at  the  Foramen  Ovale. 

Anutoiiiy. — The  nerve  on  leaving  the  foruiacn  ovale  is  im- 
mediately joined  by  the  motor  part  of  the  fifth  nerve  (Fig.  64). 
A  little  way  below  the  foramen  the  nerve  breaks  up  into  two 
divisions,  an  anterior  small  or  upper  division,  and  a  posterior, 
large,  or  inferior  division.  From  the  tnmk  arise  four  nerves 
— the  recurrent  branch  to  the  dura  mater,  which  enters  the 


INFERIOR    MAXILLARY   NERVE. 


235 


1 

% 

:> 

IP.T.T. 
_.  '.    TP 

^ 

=:     ,  ..     RT. 

R. 
A.T 

\  ^        AT 

M-H 

ID. 

&. 

skull  through  the  foramen  spinosum  ;  the  internal  pterygoifl 
nerve  ;  and  the  nerves  to  the  tensor  tynipani  and  tensor  palati. 

From  the  anterior  division  arise  four  nerves,  the  temporal 
(anterior,  middle  and  posterior) ; 
the  masseteric  (from  the  pos- 
terior temporal) ;  the  buccal 
(with  the  anterior  temporal) ;  and 
the  external  pterygoid  (Figs.  64, 
66,  and  67). 

From  the  posterior  division 
arise  also  four  nerves,  the  auri- 
culo-temporal,  the  gustatory,  the 
inferior  dental,  and  the  mylo- 
hj'oid. 

The  foramen  ovale  is  situated 
opposite  to  the  eminentia  ar- 
ticularis  at  the  root  of  the  zy- 
goma, and  is  about  one  inch 
and  a  quarter  from  that  process 
of  bone,  lying  in  a  line  trans- 
verse to  the  long  axis  of  the 
skull.  The  foramen  is  about  a 
quarter  of  an  inch  in  front  of 
the  spinous  process  of  the 
sphenoid,  and  is  immediately 
behind    the    free    edge    of  the 

pterv^goid  plate.     These  two  points  of  bone,  together  with  the 
eminentia  articularis  form  excellent  landmarks. 

The  small  meningeal  artery  which  passes  through  the  fora- 
men ovale  can  scarcely  escape  division.  The  middle  menin- 
geal which  enters  the  foramen  spinosum  is  in  gTcat  risk.  The 
trunk  of  the  nerve  and  the  larger  division  lie  under  cover  of 
the  external  pterygoid  muscle. 

The  internal  maxillary  artery  crosses  the  inferior  dental, 
gustatory,  and  buccal  nerves,  but  lies  below  the  main  trunk  of 
the  nerve.  In  forty  per  cent,  of  bodies  the  artery  passes 
beneath  the  lower  head  of  the  external  pterygoid  and  then 
emerges  between  that  head  and  the  upper  one.  The  extensive 
pterygoid  plexus  of  veins  lies  with  the  artery  over  the  muscle 
in  question. 


Fig.  64. — DIAGRAM  OF  THE  THIRD 
DIVI.SIOX    OF   THE   FIFTH    NERVE. 

F  o,  Foramen  ovale  (below  this  the 
motor  root  joins  the  nerve)  ;  F  s, 
Foramen  spinosum  ;  R.  Eecurrent 
branch  ;  A  T,  Auriculo-temp. 
nerve  ;  SI  H,  Mylo-hyoid  nerve  ; 
I  D,  Inferior  dental  nerve  ;  g. 
Gustatory  nerve ;  E  P,  External 
pterygoid  branch ;  B,  Buccal 
nerve  :  a  t,  Ant.  temporal  nerve  ; 
M  T,  Mid.  temporal  nerve  ;  Ji, 
Masseteric  nerve  ;  P  T,  Post,  tem- 
poral nerve  ;  T  P,  Branch  to 
tensor  palati ;  T  T,  Branch  to 
tensor  tynipani ;  I  P,  Internal 
pterygoid  branch. 


236  OFERATIYE    SUBGEliY. 

Operation. — A  square  vertical  flap  is  cut  from  the  cheek. 
The  two  sides  of  the  flap  are  represented  by  two  vertical  lines 
which  are  parallel  with  the  anterior  and  posterior  borders  of 
the  ascending  ramus  of  the  jaw.  The  base  of  the  flap  is 
represented  by  a  transverse  line  joining  the  two  vertical  in- 
cisions about  half  way  down  on  the  ramus  of  the  jaw.  The 
free  end  of  the  flap  is  a  little  above  the  zj^goma  (Fig.  65,  a).  The 
incisions  are  carried  down  to  the  bone  at  the  free  end  of  the 
flap.  The  zygomatic  arch  is  exposed  and  its  two  ends  are  sawn 
through.  The  piece  of  bone  is  turned  down  together  with  the 
masseter  attached  to  it,  and  the  soft  parts  covering  the  upper 
part  of  the  ramus  of  the  jaw. 

Care  must  be  taken  not  to  damage  the  facial  nerve  nor  the 
parotid  duct,  both  of  which  are  below  the  base  of  the  flap. 
The  flap  is  drawn  forcibly  downwards  rather  than  dissected 
up.  After  the  bleeding  has  been  arrested  the  coronoid  process 
is  divided  and  with  the  attached  temporal  muscle  is  turned 
upwards.  The  upper  head  of  the  external  pterygoid  muscle 
is  separated  from  its  attachment  to  the  sphenoid,  and  the 
nerve  can  now  be  exposed  and  divided  with  scissors  {see 
Figs.  ^iS  and  67). 

Comment. — The  method  described  is  that  known  as 
Krbnlein's.  The  operation  was  flrst  performed  by  Pancoast  of 
Philadelphia  some  twenty  years  ago,  and  has  been  many  times 
repeated.  Pancoast's  flap  was  made  from  below  upwards  and 
had  its  base  at  the  zygoma.  He  ligatured  the  internal 
maxillary  artery  and  entirely  removed  the  coronoid  process. 
The  haemorrhage  from  the  operation  wound  is  considerable, 
and  in  one  case  at  least  (Sutton's)  the  common  carotid  had  to 
be  tied  to  arrest  it. 

The  procedure  is  attended  with  much  risk,  and  involves 
considerable  damage  to  important  tissues.  It  has  not  been 
followed  in  all  instances  by  such  benefits  as  would  appear  to 
justif}''  the  operation.  It  involves  paralysis  of  the  muscles  of 
mastication  upon  the  side  dealt  with,  paralysis  of  the  mylo- 
hyoid and  anterior  part  of  the  digastric,  and  probable  loss  of 
power  in  the  tensor  tympani  and  tensor  palati.  The  gustatory 
nerve  is  of  necessity  divided. 

2.    The  Inferior  Dental  Nerve. 

Anatomy. — This  nerve,  the  largest  branch    of  the  third 


INFEBIOB    DENTAL   NERVE. 


237 


B 


division  of  the  fifth,  descends  under  cover  of  the  external 
pterygoid  muscle,  passes  to  the  outer  side  of  the  internal 
pterygoid,  and  running  between  the  internal  lateral  ligament 
and  the  ramus  of  the  jaw,  enters  the  dental  foramen  (Figs.  66 
and  67). 

This  foramen  is  surmounted  by  a  prominent  and  usually 
sharp  projection  of  bone,  the  lingula  or  spme  of  Spix,  To  its 
apex  is  attached  the 
internal  lateral  liga- 
ment of  the  jaw,  while 
below  and  behind  it  is 
the  groove  for  the 
m^do-hyoid  nerve.  • 

The  internal  ptery- 
goid muscle  reaches  to 
the  base  of  the  lingula. 

The  nerve  is  ac- 
companied by  the  in- 
ferior maxillary  vessels 
which  lie  behind  and 
external  to  it. 

The  internal  maxil- 
lary artery  passes  for- 
wards and  inwards  at 
some  distance  above 
the  dental  foramen. 
The  gustatory  nerve  is 
nearly  parallel  with  the 
inferior  dental,  but  is 
anterior  and  internal 
to  it  and — as  viewed  from  the  mouth — is  superficial  to  it. 

Operation. — The  mouth  is  fixed  well  open  by  a  Mason's 
gag  applied  upon  the  opposite  side  or  by  a  Hutchinson's 
spring  mouth-prop  placed  betAveen  the  incisor  teeth.  The 
cheek  upon  the  side  to  be  dealt  with  is  held  open  by  means  of 
two  blunt  hooks  which  are  so  drawn  upon  as  to  make  the 
opening  of  the  mouth  at  this  angle  as  wide  and  as  square  as 
possible.  If  the  tongue  be  in  the  way  it  may  be  drawn  aside 
with  tongue  forceps. 

A   good  light  is   essential,   and   the   best   is    that   given 


Fig  65.— A,  Neurotomy  of  third  division  of  fifth 
nerve;  B,  Removal  of  Meckel's  ganglion;  C,  Ex- 
posure of  brachial  plexus  ;  D,  Exposure  of  spinal 
accessory  nerve. 


238  OPERATIVE    SURGERY. 

by  a  small  electric  lamp  worn  upon  the  foreliead.  The 
surgeon  with  his  forefinger  defines  the  ascending  ramus  of 
the  jaw,  the  substance  of  the  internal  pterygoid  muscle,  and 
the  position  of  the  spLne  of  Spix.  This  latter  point  is  more 
or  less  obscured  by  the  attachment  of  the  internal  lateral 
ligament.  If  the  tongue  be  drawn  upon  the  gustatory  nerve 
may  possibh'  be  felt  beneath  the  mucous  membrane. 

The  mucous  membrane  is  now  incised  along  the  inner  side 
of  the  anterior  border  of  the  ascending  ramus  to  the  extent  of 
about  one  inch.  The  incision  is  vertical  and  is  carried  down 
to  the  bone. 

A  narrow  pointed  periosteal  elevator  is  now  used  to  detach 
the  mucous  membrane  from  the  jaw.  The  use  of  this  instru- 
ment may  be  supplemented  by  the  surgeon's  forefinger. 

The  spine  of  Spix  is  sought  for  and  must  be  clearly  defined. 
The  periosteum  must  not  be  detached  with  the  mucous 
membrane.  When  the  spine  of  bone  is  reached  the  internal 
lateral  ligament  may  be  divided  with  fine  straight  iris  scissors, 
the  utmost  caution  bemg  used. 

The  nerve  should  now  be  brought  into  view  and  be  drawn 
forwards  gently  with  a  small  blunt  hook  (Fig.  61).  Long-bladed 
dissecting  forceps  are  required  in  this  stage  of  the  operation. 
The  nei-ve  is  exposed  actually  as  it  is  entering  the  bone. 
Here  the  vessels  are  in  close  contact  with  it.  A  little  higher 
up  they  are  removed  from  the  nerve.  The  inferior  dental 
should  therefore  be  exposed  to  the  extent  of  about  half  an  inch, 
and  be  divided  with  iris  scissors  high  up.  It  may  be  possible 
to  have  entirely  isolated  the  nei've  upon  the  blunt  hook,  which 
is  of  very  small  size.  If  the  operator  proceed  too  far  above 
the  dental  foramen  he  will  come  in  contact  with  the  internal 
maxillary  artery.  From  a  quarter  to  half  of  an  inch  of  the 
cord  can  be  excised.  The  higher  section  of  the  nerve  is  made 
first.     No  sutures  are  required  for  the  wound. 

Gontrnent. — This  operation  is  very  difficult  and  very 
tedious.  It  is  not  so  readily  performed  as  is  the  procedure 
for  the  removal  of  Meckel's  ganglion.  The  great  depth  of  the 
wound,  the  narrowed  space  and  the  embarrassing  incidents 
which  are  apt  to  attend  operations  within  the  mouth,  all 
contribute  to  the  difficulties  of  the  position.  The  gustatory 
nerve  may  be  mistaken  for  the  inferior  dental  if  the  dental 


INFERIOR    DENTAL    NERVE. 


239 


foramen  be  not  clearly  made  out.     It  may  be  damaged  also 
during  the  operation. 

Much  bleeding  may  follow  the  common  accident  of 
dividing  the  inferior  dental  arter}^  In  one  case  (Dr.  Weir  of 
New  York,  Annals  of  Surgery,  June,  1887  )  the  haemorrhage 


Fig.    66.— THE    THIRD    DIVISION    OF    THE    FIFTH    NERVE. 

Lei-eille.) 


(After  Hirschfeld  and 


1,  Masseteric  nerve ;  2,  Posterior  temporal  nerve  ;  .3,  Buccal  nerve ;  4,  Branch  to 
facial  nerve  ;  5,  Anterior  temporal  nerve  ;  6,  Middle  tempoi-al  nerve  ;  7,  Auriculo- 
temporal nerve ;  8,  Its  temporal  branches ;  9,  Inferior  dental  nerve  ;  10,  Mylo- 
hyoid nerve;  11,  Gustatory  nerve;  12,  Facial  nerve. 


was  very  free  and  was  supposed  to  come  from  the  internal 
maxillary.  The  nerve  may  be  ruptured  during  the  process  ot 
exposure  by  being  roughly  drawn  upon. 

More  constitutional  disturbance  will  usually  follow  this 
operation  than  will  attend  the  operation  for  the  removal  ot 
Meckel's  oanoflion.     This  has  been  so  in  the  two  cases  in  which 


240  OPERATIVE    SURGERY. 

I  have  performed  both  operations  (at  different  periods)  upon 
the  same  patient.  The  fauces  are  swollen,  the  jaw  is  stiff,  th& 
tongue  is  swollen,  and  the  whole  face  aches.  The  mouth  must 
be  kept  constantly  washed  with  an  antiseptic  solution  (e.g., 
carbolic  acid  lotion,  1  in  60  or  80). 

Other  Modes  of  Operating  : — 

Other  operations  emplo3'ed  are  concerned  with  the 
exposure  of  the  nerve  from  the  face.  The  more  important  of 
them  are  briefly  described  by  MacCormac  in  the  following- 
words  :  "  Velpeau  reached  the  nerve  from  an  opening  made 
through  the  ascending  ramus  of  the  jaw,  while  Ktihn  exposed 
it  from  below  after  resecting  a  portion  of  the  angle  of  the  jaw. 
Liicke  has  modified  Klihn's  operation.  He  makes  an  mcision 
around  the  angle  of  the  jaw  corresponding  to  the  insertion  of 
the  masseter  muscle,  raises  the  soft  parts  from  the  internal 
surface  with  an  elevator,  until  the  inferior  dental  nerve,  and  in 
front  of  it  the  lingual,  can  be  felt  with  the  finger ;  a  hook  is 
then  passed  round  the  nerve  just  as  it  enters  the  canal. 

"If  the  nerve  is  to  be  reached  directly  through  the  inferior 
maxilla  (which  is  an  easy  and  direct  method)  a  curved 
incision,  convex  downwards,  about  two  inches  long,  must  be 
made  through  the  masseter  muscle  down  to  the  bone. 

"  When  this  is  exposed  the  periosteum  must  be  raised  so 
that  the  central  portion  of  the  ascending  ramus  is  laid  bare, 
and  the  detached  soft  parts  are  then  drawn  upwards.  In  this 
way  the  parotid  gland,  Stenson's  duct,  and  the  facial  nerve,  are 
preserved  from  injury.  According  to  VeJpeau's  procedure  the 
bone  over  the  opening  of  the  canal  is  removed  with  a  trej^hine. 
We  must  remember  in  using  this  instrument  that  the  jaw  is 
much  thicker  below  than  above  ;  and  hence  the  trephine  should 
be  laid  aside  when  the  upper  part  of  the  jaw  has  been  divided, 
and  the  rest  of  the  circle  of  bone  must  be  detached  by  means 
of  the  elevator  and  chisel.  If  care  be  not  taken,  the  artery  as 
well  as  the  nerve  may  be  cut  through  during  the  operation, 
and  the  ble(;ding  is  sometimes  very  severe.  Linhart  makes  a 
vertical  incision  through  the  masseter  for  its  whole  length, 
and  detaches  it  on  each  side  from  the  bone,  together  with  the 
periosteum  ;  he  then  cuts  away  the  external  table  of  the  bone 
with  a  chisel,  and  thus  exposes  the  canal  for  the  space  of  half 
an  inch,  and  resects  the  nerve. 


GUSTATORY   NERVE.  241 

"  The  nerve  may  be  likewise  exposed  by  cutting  out  a  V-  or 
U-shaped  piece  of  the  ascending  ramus  of  the  maxillary  bone, 
the  base  of  the  excised  portion  of  the  bone  being  at  the 
coronoid  notch,  and  the  apex  a  little  below  the  opening  of  the 
inferior  dental  canal.  The  coronoid  process  can  be  easily 
felt  from  within  the  mouth  when  the  jaw  is  depressed.  Its 
position  determined,  a  vertical  incision,  two  inches  long,  must 
bo  made  through  the  integuments  over  the  middle  of  the 
ascending  ramus  of  the  jaw,  the  masseter  is  sufficiently  dis- 
sected from  its  attachment  to  the  ramus,  and  the  periosteum 
is  detached  with  it. 

"  The  necessary  amount  of  bone  may  then  be  removed  with 
the  chisel,  or  by  means  r.f  a  cylindrical  drill,  half  an  inch  in 
length  and  the  same  in  diameter,  inserted  into  the  mandril  of 
a  powerful  surgical  engine.  By  it,  in  revolutions  to  the  extent 
of  5,000  times  in  a  minute,  the  nerve  is  quickly  laid  bare  at 
its  place  of  entrance  in  the  inferior  dental  foramen.  Next,  the 
opening  is  enlarged  until  the  internal  pterygoid  muscle  is  fairly 
exposed  to  view ;  the  nerve  is  cut  below,  lifted  fi'om  its  bed, 
and,  while  held  on  the  stretch,  may  be  isolated  up  to  the  point  of 
emergence  at  the  base  of  the  skuU  by  the  handle  of  a  scalpel 
Finally,  it  is  excised  with  a  pair  of  delicate  iris  scissors." 

Comment. — These  operations  are  more  easily  accompUshed 
by  the  surgeon,  but  are  of  greater  gravity  to  the  patient,  and 
in  no  instance  can  the  difficulty  which  attends  the  intra- 
buccal  operation  be  made  an  excuse  for  selecting  one  of  these 
more  serious  procedures. 

These  operations  could  only  be  justifiable  when,  for  one  or 
other  reason,  the  exposure  of  the  nerve  through  the  mouth  is 
impracticable. 

3.  The  Gustatory  Nerve. 

Anatomy. — The  gustatory  nerve  is  internal  and  anterior 
to  the  inferior  dental,  and  lies  between  the  internal  pterygoid 
muscle  and  the  internal  lateral  ligament.  It  is  curved,  with 
its  concavity  forwards,  and  lies  quite  superficially  between  the 
level  of  the  last  molar  and  the  angle  of  the  jaw  (Figs.  66 
and  67). 

Operation. — The    mouth   having   been   opened   and    the 
cheek  drawn  aside  as  in  the  previous  operation,  the  tongue  is 
drawn  forwards  and  towards  the  opposite  side. 
Q 


242 


OPERATIVE    SURGERY. 


With  the  fore-tinker  the  surgeon  can  define  the  ramus  of 
the  jaw  and  the  pterygo-maxillary  hgament.  The  nerve  can 
usually  be  felt  beneath  the  mucous  membrane  behind  the 
last-named  Hgament,  and  about  half  an  inch  behind  and 
below  the  last  molar  tooth. 

A  vertical  incision,  about  an  inch  in  length,  is  made 
through  the  mucous  membrane  over  the  nerve,  and  there- 
fore midway  between 
the  tono^ue  and  the 
gum,  and  at  the  level 
of  the  last  molar. 

The  nerve  is  ex- 
posed, is  drawn '  for- 
wards by  means  of  a 
small  blunt  hook  (Fig. 
61),  and  some  half- 
inch  is  excised. 

Comment.  —  Sec- 
tion of  this  nerve  is 
frequently  carried  out 
to  relieve  the  pain  and 
the    watering   of   the 
mouth    in    cancer   of 
the  tongue.  The  nerve 
may  be   convenient!}'" 
divided  in  the  neck  at 
the  same  time  that  the 
lingual  artery  is  being 
exposed  for  ligature. 
4.  The  Auriculo-Temporal  and  Buccal  Nerves. 
Thft  auriculo-teniporal  nerve  may  be  exposed  by  a  short 
vertical  incision  as  it  crosses  the  base  of  the  zygoma,  im- 
mediately in  front  of  the  pinna  (Fig.  63).     The  nerve  is  here 
in  close  association  with  the  superficial  temporal  artery,  behind 
which  it  is  placed.     The  nerve  is  hardly  free  of  the  parotid 
gland  at  the  place  indicated. 

Of  the  buccal  nerve,  MacCormac  writes :  "  The  buccal 
nerve  may  be  found  from  within  the  mouth,  opposite  the 
middle  of  the  anterior  margm  of  the  asceiuling  ramus  of  the 
lower  jaw.      If   the   mucous   membrane   and   fibres   of    the 


Fig.    67. — DISSECTION    OP    THE   THIKD   DIVISION  OF 
THE    FIFTH    NERVE.       {ElUs's  DisSectioUS.) 

A,  Temporal  muscle  :  B,  Condyle  of  jaw ;  C,  Internal 
pterygoid ;  D,  liuccinator  ;  E,  Masseter  ;  F,  In- 
ternal lateral  ligament ;  a,  Internal  maxillary 
artery  ;  1,  Buccal  nerve  ;  2,  Masseteric  nerve  ;  3, 
Temporal  nerve  ;  4,  Auriculo-temporal  nerve  ;  o, 
Inferior  dental  nerve  ;  0,  Lingual  nerve. 


GASSERIAN   GANGLION.  243 

buccinator  be  here  vertically  divided  and  the  tissues  separated 
with  a  director,  the  nerve  will  be  exposed."  This  operation 
must  be,  however,  somewhat  uncertain.  The  nerve  on 
reaching  the  surface  of  the  buccinator  muscle  at  once  breaks 
up  into  a  number  of  fine  branches.  Some  of  these  go  to  the 
mucous  membrane  of  the  mouth :  others  form  a  kind  of 
plexus  on  the  cheek,  supply  the  skin,  and  effect  a  com- 
munication Avitli  the  facial  nerve.  The  buccal  nerve  can 
hardly  be  regarded  as  a  single  Avell-defined  trunk  after  it  has 
come  into  relation  with  the  buccinator  muscle.  A  small 
artery  accompanies  the  nerve. 

THE   GASSERIAN   GANGLION. 

The  gasserian  ganglion  has  been  removed  by  Mr.  William 
Rose  in  two  cases  of  intractable  neuralgia  (Lancet,  Nov.  ], 
1890,  and  Feb.  7,  1891).  In  the  first  case  the  eye  suppurated 
and  was  excised.  The  operation  in  the  second  case  is  thus 
described:  The  patient  w^as  a  female  aged  sixty,  who  had 
suffered  for  many  years  from  severe  neuralgia,  affecting  chiefly 
the  superior  maxillary  nerve  on  the  right  side.  Chloroform 
was  given,  and  after  stitching  the  eyehds  together  on  that  side 
in  order  to  avoid  any  accidental  injury  to  the  eye,  a  flap  of 
skin  was  dissected  forward,  the  zygoma  was  exposed,  and,  after 
openings  had  been  drilled  with  an  electro-motor,  divided  and 
drawn  down  with  the  masseter  uuiscle.  The  coronoid  process 
of  the  lower  jaw  was  next  drilled  and  divided  in  a  similar 
manner,  and  turned  up  with  the  temporal  muscle  attached. 
The  external  pterygoid  muscle  was  then  cut  through,  and  the 
foramen  ovale  reached,  into  which  the  pin  of  a  half-inch 
trephine  was  inserted,  and  a  disc  of  bone  surrounding  it  in 
this  way  removed.  The  bleeding  was  troublesome,  and  per- 
sisted for  some  time.  The  ganglion  was  seized  by  some 
specially  constructed  hooks,  one  of  which  had  a  cutting  edge 
upon  its  concave  surface ;  by  means  of  these  its  attachments 
wore  loosened  and  divided.  Perchloride  of  mercury  solution 
(1  in  3,000)  was  used  during  the  operation.  The  bones  which 
had  been  sawn  were  replaced  and  secured  in  position  by  wire 
sutures  passed  through  the  drill-holes  previously  made,  and  a 
drainage-tube  inserted.  Cyanide  gauze  dressing  was  applied. 
The  electric  illuminator  was  found  most  useful  durino-  the 
^  2 


2U  OPERATIVE    SURGERY. 

deeper  dissections.  The  patient  has  progressed  most  satis- 
factorily since  the  oj^eration,  having  had  no  return  of  the 
neuralgic  pain,  although  it  is  impossible  to  say  at  present  that 
the  whole  of  the  ganglion  was  removed.  The  sutures  were  re- 
moved from  the  eyelids  on  the  third  day ;  the  eye  was  healthy, 
but  the  conjunctiva  insensitive.  Sufficient  time  has  not  yet 
elapsed  to  allow  of  an  opinion  being  formed  as  to  the  value 
of  this  severe  operation. 

THE   FACIAL   NERVE. 

This  nerve  has  been  stretched  close  to  its  point  of  exit 
from  the  stylo-mastoid  foramen  for  the  relief  of  facial  tic  (tic 
convulsif). 

Anator)iy. — After  its  escape  from  the  stylo-mastoid  fora- 
men the  nerve  runs  downwards  and  forwards,  passmg  beneath 
or  through  a  part  of  the  parotid  gland.  As  it  approaches  the 
ascending  ramus  of  the  jaw  it  breaks  up  into  its  two  terminal 
divisions.  The  nerve  is  here  exactly  parallel  with  the  upper 
margin  of  the  digastric  muscle. 

It  is  best  found  at  a  spot  about  a  quarter  to  half  an  inch 
in  front  of  the  centre  of  the  anterior  border  of  the  mastoid 
process.  It  is  here  about  half  an  inch  from  the  stylo-mastoid 
foramen,  has  already  given  off  its  posterior  auricular  branch, 
and  is  about  to  give  oif  its  styloid  branch  (Figs.  63  and  66). 

Operation. — An  incision  is  commenced  close  behind  the 
pinna,  and  on  a  level  with  the  auditory  meatus.  It  is  carried 
downwards  and  forwards  to  a  point  immediately  below  the 
lobule,  and  is  then  prolonged,  in  a  direction  slanting  forwards, 
nearly  to  the  angle  of  the  jaw. 

A  small  incision  transverse  to  this  is  made  just  below  the 
pinna.  The  two  small  flaps  thus  marked  out  are  retracted. 
The  fascia  is  divided,  and  the  anterior  edge  of  the  sterno- 
niastoid  and  the  parotid  gland  are  exposed.  The  muscle  is 
drawn  backwards  and  the  gland  forwards  by  means  of  suit- 
able retractors. 

The  posterior  belly  of  the  digastric  is  next  exposed,  and 
the  surgeon,  keeping  to  the  upper  margin  of  the  muscle, 
seeks  for  the  nerve  at  the  point  already  indicated. 

The  nerve  is  raised  and  stretched  by  means  of  a  small 
blunt   hook.      The   anionnt   of  force   employed   is  estimated 


FACIAL    NERVE.  245 

at  4  to  5  lbs.  It  is  not  sufficient  to  raise  the  patient's 
head. 

Some  fibres  of  the  great  auricular  nerve  which  cross  the 
trunk  of  the  facial  will  be  divided. 

The  posterior  auricular  vein  crosses  the  line  of  the  opera- 
tion, and  will  probably  need  to  be  divided  and  hgatured.  The 
companion  artery,  if  exposed,  should  be  dra^'iTi  downwards. 

To  avoid  needless  injury  and  disturbance  of  parts,  Dr.  Keen 
(Trans,  of  the  Araer.  Surg.  Assoc,  vol.  iv.,  1886)  advises  the  use 
of  a  weak  faradic  current.  A  wet  sponge  connected  with  one 
electrode  is  held  to  the  cheek,  and  a  fine  wire  connected  with 
the  other  is  applied  to  various  points  in  the  wound  till  the 
nerve  is  found.  The  same  author  advises  that  the  nerve  be 
stretched  centripetally,  and  that  the  amount  of  force  em- 
ployed be  only  limited  by  the  strength  of  the  nerve,  the 
stretching  being  discontinued  the  moment  any  fibres  give 
way. 

Comment. — This  operation  is  that  known  as  Baum's.  It 
is  described  and  illustrated  by  Godlee  in  the  Clinical  Society 
Transactions,  vols.  xiv.  and  xvi. 

Mr.  Godlee  points  out  that  the  operation  is  difficult  in 
muscular  subjects,  but  is  comparatively  easy  in  thin  patients. 
He  urges  the  use  of  a  good  hght,  of  good  retractors,  and  of 
vigorous  sponging. 

The  result  of  the  operation  has  on  the  whole  not  been 
very  encouraging.  Dr.  Keen  (loc.  cit.)  has  collected  twenty- 
one  reported  examples  of  the  oj^eration.  In  all  the  facial 
paralysis  produced  disappeared  in  a  few  days,  weeks,  or 
months.     The  results  are  as  follows : 

Relief  for  less  than  7  da^'s       .........  3  cases 

Relief  for  3  to  12  weeks.         . .  6     ,, 

Reliff  for  12  weeks  to  12  months    .         . 6     „ 

Relief  for  periods  of  a  year  or  more  or  up  to  the  time  of  the  report       .  6     ,, 

Cases  not  completed        ........         .         .  2     „ 

Mr.  Godlee  writes  :  "  In  discussing  the  question  of  recom- 
mending the  operation  to  a  patient,  we  must  not  forget  that 
the  risk,  with  due  care,  is  almost  nil ;  that  a  certain  immunity 
from  the  trouble  may  be  safely  promised  for  a  time,  and  while 
Southam's  remarkable  case  remains  completely  AveU  (more 
than  five  years  after  the  operation)  there  is  always  the  hope 


246  OPERATIVE    SURGERY. 

that  the  relief  may  be  permanent.  Were  it  not  for  this,  how- 
ever, I  am  afraid  that  the  general  verdict  would  be  that  the 
time  has  come  when  this  small  chapter  of  surgical  therapeutics 
must  be  closed." 

THE  BRACHIAL  PLEXUS  IN  THE  NECK. 

This  plexus — formed  by  branches  from  the  four  lower 
cervical  and  the  greater  part  of  the  first  dorsal  nerves — 
hes  between  the  anterior  and  middle  scalene  muscles,  and 
crosses  the  floor  of  the  posterior  triangle  of  the  neck.  The 
plexus  is  of  triangular  outline,  the  base  being  at  the  spine, 
and  the  apex  to  the  outer  side  of  the  subclavian  artery  below 
the  clavicle.  In  thin  subjects,  when  the  shoulder  is  de- 
pressed and  the  head  turned  to  the  opposite  side,  some  cords 
of  the  plexus  can  be  felt  through  the  skin. 

Operation. — The  position  of  the  j^atient  should  be  the 
same  as  is  assumed  in  ligaturing  the  third  part  of  the  sub- 
clavian artery  (see  page  139). 

The  plexus  ma}^  be  reached  by  a  vertical  incision,  some 
three  inches  in  length,  which,  commencing  about  half  an 
inch  above  the  centre  of  the  clavicle,  is  continued  upwards 
through  the  lower  part  of  the  posterior  triangle.  The  wound 
will  be  parallel  with  the  anterior  border  of  the  trapezius,  and 
will  be  but  little  removed  from  the  sterno-mastoid  muscle 
(Fig.  65,  c). 

The  integument  and  platysma  having  been  divided,  the 
external  jugular  vein  must  be  sought  for,  secured  between  two 
ligatures,  and  severed.  It  is  possible  that  in  some  instances 
the  vein  may  be  left  untouched,  and  may  be  merely  drawn 
downwards  and  inwards  out  of  the  way.  The  supra-clavicular 
branches  of  the  cervical  plexus  will  be  encountered. 

The  deep  cervical  fascia  must  in  the  next  place  be  divided 
in  the  full  length  of  the  incision. 

If  the  finger  be  now  introduced  into  the  depths  of  the 
triangle  the  cords  of  the  plexus  will  be  felt,  and  can  be 
exposed  by  a  little  careful  dissection.  The  clear  outer  border 
of  the  anterior  scalene  muscle  should  be  defined.  The  omo- 
hyoid muscle  will  be  exposed  in  the  lower  part  of  the  incision, 
and  should — if  necessary — be  drawn  downwards. 


CERVICAL    PLEXUS.  -  247 

The  superficial  cervical  artery  and  vein  cross  the  plexus 
transversely  about  its  middle,  and  must  be  carefidly  sought 
for  and  protected.  If  the  linger  be  passed  along  the  plexus  to 
the  interval  between  the  anterior  and  middle  scalene  muscles 
there  is  no  difficulty  in  identifying  any  particular  cord. 

BRANCHES   OF   THE   CERVICAL   PLEXUS. 

The  sensory  branches  of  this  plexus  are  readily  reached 
by  an  incision  about  one  and  a  half  or  two  inches  in  length, 
which  is  placed  over  the  posterior  border  of  the  stemo- 
mastoid  muscle  and  at  such  a  height  in  the  posterior  triangle 
that  the  centre  of  the  incision  will  correspond  to  the  centre  ot 
the  muscle. 

The  position  of  the  chief  superficial  nerves  of  the  neck 
may  be  fairly  indicated  by  six  lines  all  drawn  from  the  centre 
of  the  posterior  margm  of  the  sterno-mastoid. 

A  line  drawn  forwards  from  this  spot  so  as  to  cross  the  sterno- 
mastoid  at  right  angles  to  its  long  axis,  corresponds  to  the 
superficial  cervical  nerve.  A  second  hne  drawn  upwards 
across  the  muscle  to  the  back  of  the  pinna,  so  as  to  run  parallel 
with  the  external  jugular  vein,  corresponds  to  the  great 
auricular  nerve  ;  and  a  third  line,  running  along  the  posterior 
border  of  the  sterno-mastoid  muscle  to  the  scalp,  marks  the 
course  of  the  small  occipital  nerve.  These  lines,  continued 
downwards,  so  as  to  cross  the  sternum,  the  middle  of  the 
clavicle,  and  the  acromion,  will  indicate  respectively  the  supra- 
sternal, supra-clavicular,  and  supra-acromial  nerves. 

THE   SPINAL    ACCESSORY   NERVE. 

Stretching,  neurotomy,  and  neurectomy  of  this  nerve  have 
been  performed  for  the  relief  of  spasn)odic  torticollis  of  an 
intractable  form.  The  first  two  operations  have  been  attended 
only  by  temporary  relief,  the  last  named  with  a  very  fair 
degree  of  success. 

Anatoray. — The  spinal  section  of  the  nerve  leaves  the 
foramen  lacerum  posterius  with  the  pneumo-gastric,  and  in 
the  same  sheath  with  it.  It  then  passes  downwards  and  back- 
wards  across    the   front   of    the   internal  jugular   vein   and 


248  OPERATIVE    SURGERY. 

beneath  the  digastric  and  stylo-hyoid  muscles  and  the 
occipital  artery.  When  clear  of  the  digastric  it  enters  the 
deep  part  of  the  sterno-mastoid  at  its  upper  fourth  at  a  point 
about  two  inches  below  the  tip  of  the  mastoid  process  in  a 
vertical  line.  It  traverses  the  muscle  in  its  second  fourth, 
and  emerges  from  beneath  it  at  a  point,  on  a  level  with  the 
centre  of  its  posterior  border.  Crossing  the  posterior  triangle 
obliquely,  the  nerve  passes  beneath  the  anterior  border  of  the 
trapezius  muscle  at  about  the  upper  part  of  its  lower  third, 
and  is  lost  in  the  muscular  tissue.  Just  below  the  skull  the 
course  of  the  nerve  is  represented  roughly  by  a  line  drawn  at 
right  angles  to  another  line  which  passes  from  the  tip  of  the 
mastoid  to  the  angle  of  the  jaw. 

Operation.- — ^The  shoulders  are  raised,  the  head  is 
thrown  a  little  back,  and  the  face  is  turned  to  the  opposite 
side. 

An  incision  three  inches  in  length  is  made  along  the 
anterior  border  of  the  sterno-mastoid  muscle,  commencing 
above  at  the  tip  of  the  mastoid  process.  The  skin  and  super- 
ficial tissues  having  been  divided,  the  anterior  border  of  the 
muscle  is  exposed  and  the  cervical  fascia  freely  opened 
(Fig.  65,  D). 

The  neck  being  relaxed  a  little,  the  sterno-mastoid  is  then 
dra^vn  forcibly  backwards  by  an  angular  steel  retractor.  This 
will  serve  to  put  the  nerve  upon  the  stretch  and  to  bring  it  a 
little  nearer  to  the  surface. 

On  careful  examination  with  the  finger  the  nerve  may 
usually  be  felt  at  this  stage.  The  best  guide  to  its  position  is 
the  conspicuous  transverse  process  of  the  atlas,  since  the 
nerve  crosses  almost  directly  over  that  process  of  bone.  The 
inferior  border  of  the  digastric  muscle  should  be  defined,  and 
passing  from  beneath  the  digastric  to  the  sterno-mastoid  across 
the  site  of  the  atlantoid  process  the  nerve  can  readily  be 
exposed  by  a  little  dissection. 

Comment. — Although  the  nerve  is  very  deeply  placed  in 
its  course  from  the  foramen  lacerum  to  the  sterno-mastoid  the 
operation  is  not  difficult.  The  exposure  of  the  spinal  accessory 
in  the  posterior  triangle  is  a  simpler  proceeding,  but  of  very 
limited  applif-ability,  as  division  of  the  nerve  will  affect  the 
trapezius  only.    Mr.  Campbell  de  Morgan  {Brit,  and  For.  Med.- 


POSTERIOR    CERVICAL   NERVES.  249 

€hir.  Rev.,  1886)  exposed  the  nerve  in  the  posterior  triangle, 
and  then  followed  it  up  beneath  the  sterno-mastoid  until  he 
was  enabled  to  divide  the  sterno-mastoid  portion  of  the  nerve. 
The  operation  was  very  successful.  Mr.  Jacobson  ("  The 
Operations  of  Surgery,"  page  461)  performed  the  same  opera- 
tion, but  with  a  less  satisfactory  result.  Mr.  Jacobson  is  in 
favour  of  dividing  the  nerve  above  the  sterno-mastoid,  regard- 
ing it  as  more  certain  and  not  really  more  difficult. 

An  interesting  paper  b}'^  Mr.  Ballance  upon  this  operation 
will  be  found  in  the  fourteenth  volume  of  the  St.  Thomas's 
Hospital  reports. 

THE   POSTERIOR   CERVICAL   NERVES. 

Dt.  Keen  (Annals  of  S'wrgery,3di-Q..,  1891)  advises  the  divi- 
sion or  excision  of  the  nerves  supplying  the  posterior  rotator 
muscles  of  the  head  in  certain  cases  of  spasmodic  wry-neck. 
The  nerves  concerned  are  the  posterior  divisions  of  the  first 
three  cervical  nerves.  Dr.  Keen  has  performed  the  operation 
once  only.  The  steps  of  the  procedure  are  detailed  as  follows : 
Make  a  transverse  incision  about  half  an  inch  below  the  level 
of  the  lobule  of  the  ear,  from  the  middle  line  of  the  neck 
posteriorly.  This  incision  should  be  two  and  a  half  to  three 
inches  long.  Divide  the  trapezius  transversely,  and  find  the 
occipitalis  major  nerve  as  it  emerges  from  the  complexus  and 
enters  the  trapezius.  In  the  complexus  is  an  intra-muscular 
aponeurosis.  The  nerve  emerges  from  the  complexus  at  a 
point  between  this  aponeurosis  and  the  middle  line,  usually 
about  half  an  inch  below  the  incision,  but  sometimes  higher 
up,  and  then  enters  the  trapezius. 

Divide  the  complexus  transversely  at  the  level  of  the 
nerve.  Dissect  the  nerve  down  where  it  arises  from  the 
posterior  division  of  the  second  cervical.  Resect  a  portion  of 
the  posterior  division  before  the  occipitahs  major  arises  from 
it,  so  as  to  include  the  filament  to  the  inferior  obhque  muscle. 
This  divides  the  second  cervical. 

Define  the  inferior  oblique  muscle  by  following  the  sub- 
occipital nerve  towards  the  spine. 

Define  the  sub-occipital  triangle.  In  this  triangle  Hes  the 
sub-occipital.  It  should  be  traced  do^vn  to  the  spine  itself, 
and  be  resected.     This  divides  t\iejirst  cervical. 


250  OPEliATIVE    SVRGERY. 

An  inch  lower  do^vn  than  the  occipitahs  major,  and  under 
the  comjjlexns,  is  the  external  branch  of  the  posterior  division 
of  the  third  cervical  to  the  splenius.  When  found,  it  is  to  be 
divided  close  to  the  bifurcation  of  the  main  trunk.  This 
divides  the  ihird  cervical. 


251 


CHAPTER    III. 

Operations  upon  the  Nerves  of  the  Upper  Extremity. 

1.  the  median  nerve. 

Anatomy.  —  This  nerve  is  superficially  placed  in  the  arm 
and  at  the  wrist,  but  has  a  deep  course  in  the  forearm.  In  the 
arm,  it  is  in  close  relation  with  the  brachial  artery,  lying  to  its 
outer  side  above,  crossing  it  about  the  middle  of  its  course, 
and  lying  to  its  inner  side  at  the  bend  of  the  elbow.  In  the 
forearm  the  median  lies  in  the  middle  of  the  limb,  between 
the  deep  and  superficial  fiexors  of  the  fingers.  At  the  wrist  it 
can  easily  be  made  out  between  the  tendons  of  the  flexor 
carpi  radialis  and  the  palmaris  longus. 

Operations. — (a)  In  the  arm  the  nerve  can  be  exposed 
through  such  an  incision  as  is  employed  to  secure  the  brachial 
artery,  e.g.,  in  the  middle  of  the  arm  (page  126). 

{h)  At  the  wrist  it  is  readily  exposed  through  an  incision 
about  one  inch  and  a  half  in  length  which  is  parallel  with  the 
tendon  of  the  flexor  carpi  radialis  and  close  to  its  ulnar  side. 
A  superficial  vein  or  so  ma}^  be  cut,  the  fascia  is  divided  and 
the  nerve  can  at  once  be  brought  into  view. 

2.  the  ulnar  nerve. 

Anatomy. — The  uhiar  nerve  is  superficial  in  the  arm, 
being  covered  only  by  the  skin  and  fascia.  It  follows  at 
first  the  line  of  the  brachial  artery,  lying  to  the  inner  side  of 
that  vessel.  It  is  then  represented  by  a  line  drawn  from 
the  inner  side  of  the  artery  about  the  level  of  the  insertion 
of  the  coraco-brachialis  to  the  gap  between  the  inner  condyle 
and  the  olecranon.  In  this  latter  part  of  its  course  in  the 
arm  it  is  accompanied  by  the  inferior  profunda  artery,  which 
lies  to  its  outer  side.     It  passes  betAveen  the  two  heads  of  the 


252  OPERATIVE    SURGERY. 

flexor  carpi  ulnaris,  and  runs  under  cover  of  that  muscle  a 
straight  course  to  the  wrist. 

In  the  upper  two-thirds  of  the  forearm  it  is  deeply  placed ; 
but  in  the  lower  third  it  is  superiicial,  having  the  tendon  of 
the  flexor  carpi  ulnaris  on  its  inner  side  and  the  ulnar  artery 
on  its  outer  side.  It  crosses  the  anterior  annular  ligament 
between  the  pisiform  bone  and  the  ulnar  artery. 

The  dorsal  branch  to  the  hand  leaves  the  trunk  some  two 
or  three  inches  above  the  wrist. 

At  the  elbow  the  nerve  has  been  found  passing  in  front  of 
the  internal  condyle. 

Operations. — (a)  Above  the  centre  of  the  arm  the  nerve 
may  be  exposed  by  an  incision  parallel  to  the  line  of  the 
brachial  artery  and  half  an  inch  to  the  inner  side  of  it.  In 
exposing  the  nerve  care  must  be  taken  to  avoid  injury  to  the 
vense  comites  of  the  brachial  artery,  the  nerve  of  Wrisberg,  and 
the  ulnar  collateral  nerve,  all  of  which  are  in  near  association 
with  the  trunk  sought  for. 

(6)  The  ulnar  nerve  is  very  conveniently  exposed  just 
above  the  internal  condyle.  The  incision  should  be  about  one 
inch  and  three-quarters  in  length  and  should  lie  upon  the 
line  for  the  nerve  already  given.  The  cut  should  extend  to 
within  about  half  an  inch  of  the  internal  condyle.  The  nerve 
is  found  to  lie  along  the  back  of  the  internal  inter-muscular 
septum  with  the  inferior  profunda  artery  which  is  placed  to  its 
outer  side. 

(c)  Just  above  the  wrist  the  nerve  may  be  exposed  by 
means  of  an  incision  one  inch  and  a  half  long  made  parallel  to 
the  tendon  of  the  flexor  carpi  ulnaris  and  just  to  its  outer  side. 
After  the  integuments  and  fascia  have  been  divided  the  nerve 
is  brought  at  once  into  view,  the  artery  lying  to  its  radial  side. 

3,   THE   MUSCULO-SPIRAL   NERVE. 

AniatoTny. — Commencing  behind  the  axillary  vessels  this 
nerve  nms  backwards  into  the  musculo-spiral  groove,  accom- 
panied by  the  superior  profunda  artery ;  on  reaching  the  outer 
side  of  the  limb  it  pierces  the  external  inter-muscular  septum, 
about  midway  between  the  insertion  of  the  deltoid  and  the  tip 
of  the  external  condyle,  and  descending  between  the  supinator 
longus  and  the  brachialis  anticus  divides  about  the  level  of 


MUSGULO-SPIBAL    NERVE.  253 

the  outer  condyle  into  the  radial  and  posterior  interosseous 
nerves.  The  superior  profunda  artery  on  reaching  the  outer 
side  of  the  humerus  breaks  up  into  two  branches,  the  larger 
of  which  descends  along  the  back  of  the  inter-muscular 
septum  to  reach  the  outer  condyle,  while  the  smaller  follows 
the  nerve  into  the  groove  between  the  supinator  longus  and 
brachialis  muscles. 

The  nerve  above  the  point  at  which  it  pierces  the  inter-mus- 
cular septum  will  have  given  off  the  nerve  to  the  long  head  of 
the  triceps,  the  posterior  internal  cutaneous,  the  branches  to 
the  inner  and  outer  heads  of  the  triceps  and  to  the  anconeus 
and  the  posterior  external  cutaneous. 

In  the  groove  between  the  supinator  longus  and  the  bra- 
chialis anticus,  it  gives  off  branches  to  both  those  muscles, 
to  the  extensor  carpi  radialis  longior  and  to  the  elbow-joint.' 

Operation. — The  nerve  is  most  conveniently  exposed  at  the 
point  at  which  it  gains  the  outer  side  of  the  arm.  The  elbow 
is  flexed  and  the  arm  carried  a  little  across  the  patient's  thorax. 

An  incision,  from  two  to  two  and  a  half  inches  in  lensfth  is 
made  obliquely,  across  the  outer  surface  of  the  arm  at  its 
lower  third. 

The  centre  of  the  incision  is  made  to  correspond  to  a  point 
midway  between  the  insertion  of  the  deltoid  and  the  external 
condyle,  and  its  obliquity  is  so  determined  that  the  lower  part 
of  the  incision  will  follow  the  line  of  the  upper  border  of  the 
supinator  longus. 

The  skin  and  fascia  having  been  divided,  the  surgeon  with 
his  forefinger  seeks  for  the  nerve  as  it  lies  close  to  the  bone, 
piercing  the  inter-muscular  septum,  and  about  to  cross  the 
upper  limit  of  the  supinator  muscle. 

If  the  fibres  of  this  muscle  be  exposed  the  position  of  the 
nerve  can  be  more  readily  determined. 

The  supinator  muscle  may  be  drawn  outwards  so  as  to  de- 
monstrate the  groove  between  it  and  the  brachialis  anticus. 
The  nerve  may  be  carefully  separated  from  the  companion 
artery  and  drawn  forwards  by  means  of  a  blunt  hook. 


•264 


CHAPTER    IV. 

Operations  upon  the  Nerves  of  the  Lower  Extremity. 

1.  the  great  sciatic  nerve. 

AThotomy.  —  This,  the  largest  nerve  m  the  body,  extends 
from  the  lower  border  of  the  pyriformis  muscle  to  a  point  a 
little  below  the  middle  of  the  thigh,  where  it  separates  into  its 
two  divisions,  internal  and  external  popliteal 

It  rests  upon  the  external  rotators  of  the  hip  and  upon  the 
adductor  magnus.  It  is  covered  behind  by  the  gluteus  maxi- 
mus  and  the  hamstring  muscles. 

It  lies  in  the  hollow  between  the  great  trochanter  and  the 
tuber  ischii,  being  a  little  nearer  to  the  latter  than  to  the 
former  process  of  bone.  The  small  sciatic  nerve  lies  in  the 
same  line  as  the  great  cord  but  superficial  to  it.  The  comes 
nervi  ischiadici  accompanies  the  great  sciatic. 

The  bifurcation  of  the  nerve  may  take  place  at  any 
point  between  the  sacral  plexus  and  the  lower  third  of  the 
thigh. 

The  "  fold  of  the  buttock  "  is  considerably  above  the  level 
of  the  lower  border  of  the  gluteus  maximus,  with  which  there- 
fore it  does  not  correspond.  When  the  hip  is  fully  extended, 
as  in  the  erect  posture,  the  buttocks  are  round  and  prominent, 
he  gluteal  fold  is  transverse  and  very  distinct.  When  the  hip 
is  a  little  t^cxed,  the  buttocks  become  flattened,  the  gluteal 
fold  becomes  oblique  and  to  a  large  extent  disappears. 

Operation. — The  nerve  is  most  accessible  for  .stretching  if 
exposed  at  the  lower  border  of  the  gluteus  maximus  muscle, 
just  as  it  is  leaving  the  hollow  between  the  tuber  ischii  and 
the  great  trochanter.  This  corresponds  to  its  most  superficial 
part. 

The  patient  should  be  turned  sufficiently  over  upon  the 
face  to  enable  the  buttock  to  be  exposed  and  the  thigh  to  be 


GEE  AT   SCIATIC    NERVE.  255 

extended.  A  vertical  incision,  four  inches  in  length,  is  then 
made  in  the  course  of  the  nerve. 

The  incision  should  commence  over  the  gluteal  fold,  and 
should  be  exactly  opposite  to  the  middle  of  the  interval  be- 
tween the  tuber  ischii  and  the  great  trochanter.  If  the  wound 
be  made  nearer  to  the  tuber  there  is  an  increased  difficulty  in 
displacing  the  hamstring  muscles. 

The  centre  of  the  incision  will  about  correspond  to  the  free 
lower  margin  of  the  gluteus  maximus. 

The  skin  and  fascia  having  been  divided,  the  small  sciatic 
nerve  and  a  few  cutaneous  arteries  will  be  encountered.  The 
quantity  of  the  subcutaneous  fat  may  be  considerable. 

The  lower  border  of  the  gluteus  maximus  should  be  clearly 
exposed  as  it  runs  obliquely  doAvnwards  and  outwards. 

The  edge  of  this  muscle  must  be  drawn  upwards  b}^  means 
of  a  strong  and  somewhat  broad  retractor. 

The  finger  introduced  into  the  wound  will  now  encounter 
the  hamstring  muscles  a  little  below  their  origin  from  the 
tuber  ischii.  These  muscles  should  all  be  drawn  inwards, 
their  fibres  having  been  first  relaxed  by  bending  the  knee. 
They  are  retained  in  position  by  another  strong  and  broad 
retractor. 

The  nerve  should  now  be  readily  discovered  and  brought 
into  view. 

2.  THE   INTERNAL  POPLITEAL   NERVE. 

This  nerve,  the  larger  of  the  two  divisions  of  the  great 
sciatic,  continues  the  direction  of  the  main  trunk,  passes 
through  the  middle  of  the  popliteal  space,  and  at  the  lower 
margin  of  the  popliteus  muscle  ends  as  the  posterior  tibial 
nerve. 

The  internal  popliteal  can  be  very  conveniently  reached 
through  the  incision  made  for  ligaturing  the  lower  part  of  the 
popliteal  artery  (page  186). 

3.  THE   EXTERNAL   POPLITEAL   NERVE. 

Anatomy. — The  external  popliteal  or  peroneal  nerve  follows 
the  outer  side  of  the  popliteal  space,  lying  close  to  the  biceps. 
Passing  over  the  outer  head  of  the  gastrocnemius,  between  it 
and  the  biceps,  the  nerve  reaches  the  neck  of  the  fibula,  and 


256  OPE  BAT IV E    SURGERY. 

crosses  that  bone  beneath  the  fibres  of  the  peroneus  longus 
muscle. 

The  nerve  may  be  easily  felt,  when  the  knee  is  a  Httle 
flexed,  as  a  loose  rounded  cord,  lying  just*  behind  the  biceps 
tendon,  as  it  nears  the  head  of  the  fibula. 

Operation. — The  patient  hes  upon  the  sound  side  with  a 
sufficient  tending  to  the  prone  position  to  well  expose  the 
outer  aspect  of  the  knee. 

The  knee-joint  is  extended.  An  incision,  one  inch  and  a 
half  in  length,  is  made  parallel  with  and  immediately 
posterior  to  the  tendon  of  the  biceps.  The  cut  should  be  so 
placed  that  its  upper  half  is  in  relation  with  the  tendon  ^^hile 
its  lower  half  is  over  the  fibula.  The  skin  and  deep  fascia 
having  been  divided  the  biceps  tendon  is  exposed. 

The  knee  should  now  be  a  little  flexed  and  the  nerve 
sought,  close  to  the  point  at  which  the  tendon  reaches  the  head 
of  the  fibula. 

A  narrow  and  unduly  prominent  ilio-tibial  band  has  been 
mistaken  for  the  biceps  tendon. 

4.  THE  ANTERIOR  CRURAL  NERVE, 

This  large  nerve  descends  into  the  thigh  in  the  groove 
between  the  psoas  and  ihacus  muscles,  and  almost  immediately 
below  Poupart's  ligament  becomes  flattened  out  and  breaks  up 
into  numerous  branches.  The  nerve  is  sej)arated  from  the 
artery  by  the  psoas  muscle. 

A  vertical  incision,  two  inches  in  length,  should  be  made 
in  the  course  of  the  nerve,  and  should  commence  a  little  above 
Poupart's  Ugament.  In  the  superficial  tissues  of  the  region 
the  crural  branch  of  the  genito-crural  may  be  met  with  and  the 
superficial  circumflex  iliac  vessels  will  cross  the  line  of  the 
wound.  The  fascia  lata  having  been  divided  and  the  hip  a 
little  flexed,  so  as  to  relax  the  muscles,  the  nerve  will  be  found 
without  difficulty.  The  edge  of  the  sartorius  muscle  need  not. 
lie  exposed. 

5.   THE   INTERNAL  SAPHENOUS   NERVE. 

Anatomy. — This  nerve  can  be  most  conveniently  reached 
at  the  inner  side  of  the  knee  opposite  to  the  inner  tuberosity 
of  the  tibia     When  the   long  saphenous  nerve  leaves  the 


INTERNAL    SAPHENOUS    NERVE.  257 

femoral  vessels  it  passes  beneath  the  sartorius  to  the  inner 
side  of  the  knee,  accompanied  by  the  superficial  branch  of  the 
anastomotica  magna  artery.  Near  the  inner  condyle  of  the 
femur  the  nerve  gives  off  its  patellar  branch,  which  becomes 
cutaneous  by  piercing  the  fascia  in  front  of  the  internal 
saphenous  vein.  The  trunk  becomes  superficial  opposite  to 
the  tibial  tuberosity  by  piercing  the  fascia  at  the  posterior 
border  of  the  sartorius. 

Operation. — An  incision,  about  one  inch  and  a  half  in 
length,  made  along  the  posterior  margin  of  the  sartorius 
opposite  to  the  tuberosity  of  the  tibia,  should  bring  the  nerve 
into  view. 

The  vein  is  an  excellent  guide  to  it,  and  as  a  rule  the  nerve 
will  be  found  to  be  just  posterior  to  the  vein. 

If  the  incision  be  made  higher  up,  the  patellar  branch  of 
the  nerve — which  lies  in  front  of  the  vein — may  be  mistaken 
for  the  main  trunk. 

At  the  site  of  the  operation  some  cutaneous  arteries  derived 
from  the  anastomotic  will  usually  be  found  with  the  nerve. 

The  nerve  is  quite  superficial  at  this  point. 

The  vein  when  exposed  should  be  gently  drawn  inwards. 


259 


^art  V. 
AMPUTATIONS. 

GEN-ERAL      CON  SI  I)  E  RATIONS. 

CHAPTER   I. 

The  History  of  the   Operation. 

The  slow  development  of  methods  for  amputating  limbs  is 
one  of  the  most  remarkable  features  in  the  history  of  surgery. 

The  conspicuous  part  which  amputations  play  in  prac- 
tice, and  the  prominent  position  they  assume  among  surgical 
operations,  render  this  circumstance  especially  noteworthy. 

The  removal  of  a  limb  by  what  may  be  termed  a  reason- 
able operation  is  a  matter  belonging  only  to  comparatively 
recent  times,  and  the  majority  of  the  procedures  now  in  use 
can  claim  no  greater  antiquity  than  pertains  to  the  last  cen- 
tury or  to  the  present. 

For  some  hundreds  of  years  amputation,  so  called,  was 
limited  merely  to  the  removal  of  gangrenous  limbs  by  cutting 
through  the  dead  part. 

The  difficulty  in  the  way  of  the  development  of  the  opera- 
tion was  the  ignorance  of  any  certain  means  of  controlling 
and  arresting  hsemorrhage. 

It  is  from  the  time  of  the  introduction  of  ligatures  for 
bleeding  vessels  and  the  invention  of  the  tourniquet  that  the 
operation  of  amputation  may  be  considered  to  date. 

Hippocrates,  "  the  Father  of  Medicine,"  who  flourished 
some  four  hundred  years  before  the  Christian  era,  had  no 
conception  of  amputation  of  a  limb  as  a  surgical  procedure. 

The  matter  is  alluded  to  in  his  account  of  gangrene  of  the 
extremities.  "  Those  parts  of  the  body,"  he  writes,  "  which 
are  below  the  boundaries  of  the  blackening  are  to  be  removed 
B  2 


260  OPERATIVE    SUBGEBY. 

at  the  joint,  as  soon  as  tliey  are  fairly  dead  and  have  lost 
their  sensibiUty ;  care  being  taken  not  to  wound  any  Hving- 
part ;  for  if  the  part  which  is  cut  off  gives  pain,  and  if  it 
should  prove  not  to  be  quite  dead,  there  is  great  danger 
lest  the  patient  may  swoon  away  from  the  pain,  and  such 
swoonings  often  are  immediately  fatal." 

For  many  centuries  this  represented  the  whole  of  the  art 
and  science  of  amputations. 

Galen  (a.d.  131 — 200),  who  wrote  some  five  hundred  years 
after  the  death  of  Hippocrates,  had  nothing  to  add  to  the 
teaching  of  the  Father  of  Medicine. 

Before  the  time  of  Galen,  however,  there  lived  in  Rome, 
in  the  early  years  of  the  first  century,  the  remarkable  surgeon 
Aurelius  Cornelius  Celsus,  the  contemporary  of  Horace,  Virgil, 
and  Ovid.  Celsus  is  the  first  writer  who  describes  a  definite 
amputation  method.  He  operated  by  what  is  now  known  as 
the  circular  plan,  but  no  account  remains  to  tell  of  his 
successes  or  his  failures. 

He  does  not  appear,  however,  to  have  influenced  surgical 
practice.  Those  who  followed  him  returned  to  the  teaching 
of  Hippocrates.  The  Celsian  operation  was  lost,  and  it  is 
evident  that  the  circular  amputation  of  recent  times  can 
claim  no  direct  connection  with  the  invention  of  the  Roman 
surgeon. 

His  description  of  the  operation  is  in  the  following  words : 
"  The  incision  is  to  be  made  with,  a  scalpel  through  the  flesh 
as  far  as  the  bone,  between  the  healthy  and  diseased  portions; 
but  not  over  a  joint,  and  it  should  rather  comprehend  a 
portion  of  the  sound  limb  than  leave  any  part  of  it  diseased. 
When  we  come  to  the  bone,  the  sound  flesh  must  be  retracted 
from  it,  and  the  section  continued  around  it,  so  as  to  lay  that 
part  of  the  bone  bare  ;  then  that  is  to  be  cut  off  with  a  small 
saw,  as  near  as  possible  to  the  sound  adherent  flesh ;  and  the 
asperities  of  the  bone  produced  by  the  saw  being  smoothed, 
the  skin  is  to  be  brought  over  it ;  Avhich  in  an  operation  of 
this  kind  ought  to  be  very  free,  in  order  to  cover  the  bone  in 
every  direction  as  much  as  possible.  The  part  which  has  not 
been  sufficiently  covered  with  skin  must  be  dressed  with  lint, 
and  a  sponge  moistened  with  vinegar  bound  over  it." 

There  is  evidence  to  support  the  belief  that  Celsus  secured 


HISTORY    OF   AMPUTATION.  261 

the  divided  blood-vessels  by  ligatures.  In  his  observations 
upon  severe  haemorrhage  from  wounds,  he  writes:  "The 
bleeding  vessels  are  to  be  taken  up,  and  two  ligatures  to  be 
applied,  one  on  each  side  of  the  wound,  and  then  to  be 
divided  between  the  ligatures." 

The  first  attempt  to  control  haemorrhage  during  an  am- 
putation is  ascribed  to  Archigenes  (a.d.  81 — 117),  who 
advised  that  the  main  vessels  of  the  limb  should  be  tied  or 
stitched  before  the  operation,  or  that  the  circulation  should 
be  arrested  for  a  while  by  means  of  a  tight  band.  The 
bleeding  from  the  stump  was  to  be  checked  b}^  the  hot  iron. 

After  the  time  of  Celsus,  however,  surgery — so  far  cer- 
tainly as  the  performance  of  amputations  was  concerned — 
remained  dormant  for  centuries,  and  showed  but  little  ad- 
vance upon  the  art  as  it  was  taught  by  Hippocrates. 

Operative  surgery  may  be  considered  to  date  from  the 
sixteenth  century — a  century  rendered  brilliant  by  the  works 
of  the  great  anatomists  Vesalius  and  Fallopius. 

It  was  in  this  century  that  Ambrose  Pare  introduced  the 
Hgature  for  the  arrest  of  traumatic  haemorrhage,  and  aj)plied 
it  to  cases  of  amputation  through  sound  parts.  The  enor- 
mous value  of  this  simple  measure  was,  however,  not  recog- 
nised for  many  years. 

"Fabricius,  of  Acquapendente  (a.d.  1537 — 1619),  returned 
to  the  old  Hippocratic  doctrine  of  cutting  through  dead  parts 
only,  while  Fabricius  Hildanus  (a.d.  1560 — 1634)  employed  a 
red-hot  knife  to  sear  the  vessels  as  they  were  cut,  thinking 
this  safer  and  more  expeditious  than  the  application  of 
ligatures.  Even  Wiseman,  the  '  father  of  English  Surgeiy,' 
{circa  1676),  though  describing  Fare's  invention,  preferred  the 
use  of  a  '  ro3'al  styptic '  or  the  actual  cautery.  Peter  Lowe, 
who  died  in  1612,  thought  the  ligature  reasonably  sure, 
providing  it  be  quickly  done  ;  but  Cooke,  of  Warwick  (circa 
1675),  refers  to  Pare  for  a  description  of  the  method  of 
'  stitching '  the  vessels,  and  adds  that  it  '  is  almost  wholly 
rejected;'  while  the  famous  (|uack  Salmon  (who  died  in 
1700)  does  not  apparently  think  it  even  worthy  of  mention." 
(Ashhurst.) 

During  the  sixteenth  and  seventeenth  centuries,  however, 
amputation  passed  through  a  period  of  development  that  can 


262  OPERATIVE    SURGERY. 

only  be  termed  barbarous.  Limbs  were  removed  by  means 
of  the  chisel  and  mallet,  the  operation  in  the  case  of  the 
hand  being  accomplished  by  one  blow.  The  very  powerful 
shears  invented  by  Botal,  of  Asti,  were  in  use,  and  it  was 
claimed  for  them  also  that  they  could  effect  the  removal  of  a 
limb  by  a  single  cut.  Sickle-shaped  and  curved  knives  were 
employed,  and,  indeed,  it  was  not  until  late  in  the  eighteenth 
century  that  the  straight  blade  was  introduced. 

John  Woodall  (1617)  was  the  first  surgeon  to  advise  am- 
putation of  the  leg  as  low  as  the  ankle  in  diseases  and  injuries 
of  the  foot. 

The  invention  of  the  tourniquet,  gripe-stick,  garrot,  or 
Spanish  windlass,  is  ascribed  by  some  to  the  French  surgeon 
Morel  (1674),  and  by  others  to  Young,  of  Plymouth  (1679). 

The  somewhat  rude  contrivances  at  first  introduced  were 
rapidly  improved,  and  the  operation  of  amputation  became, 
in  consequence,  much  simplified. 

The  later  history  of  amputation  is  very  admirably  sum- 
marised by  Ashhurst  ("  Encyclopaedia  of  Surgery,"  vol.  i.)  in 
the  followinsf  words  : — 

"  As  soon  as  surgeons  had  begun  to  emancipate  them- 
selves from  the  Hippocratic  and  Galenic  doctrine  of  cutting 
only  dead  tissues,  it  was  natural  that  they  should  adopt  the 
Celsian  method,  and  we  accordingly  find  that  the  circular 
mode  of  amputation  was  practised  at  an  earlier  period  than 
any  of  the  flap  operations. 

"The  first  important  modification  introduced  into  the 
procedure  of  Celsus  was  the  suggestion,  about  the  same  time 
and  apparently  independently  of  each  other,  by  Petit  in 
France,  and  by  Cheselden  in  England  (1749),  of  the  double 
incision  of  the  soft  parts  :  the  skin  and  superficial  fascia 
being  divided  first,  and  retracted,  and  the  muscles  cut  by  a 
second  incision  at  the  highest  point  thus  exposed 

"  Louis  practically  returned  to  the  Celsian  method,  dividing 
all  the  soft  parts  at  the  same  level,  but  sawing  the  bone  at  a 
higher  point — an  important  feature  of  the  operation,  the 
value  of  which  Petit  and  Cheselden  had  overlooked.  Louis 
also  employed  digital  compression  instead  of  the  tourniquet, 
believing  that  the  latter  interfered  with  the  retraction  of  the 
muscle. 


HISTORY    OF   AMPUTATION.  263 

"  Valentin  (1772)  advised  that  the  position  of  the  limb 
should  be  varied  at  different  stages  of  the  operation,  so  that 
the  muscles  of  each  part  should  be  left  as  long  as  possible. 

"  With  a  similar  view,  Hey,  of  Leeds,  in  amputating  the 
thigh,  divided  the  posterior  muscles  at  a  lower  level  than  the 
anterior,  in  order  that  their  greater  tendency  to  retraction 
might  thus  be  compensated  for. 

"To  this  surgeon,  together  with  Allanson,  of  Liverpool, 
and  Benjamin  Bell,  of  Edinburgh,  is  due  the  improvement  by 
which  a  sufficient  covering  was  secured  for  the  stump  by  dis- 
secting up  the  skin  and  fascia  so  as  to  form  a  cuff,  which  was 

afterwards  brousfht  down  over  the  muscles  and  bone 

When  the  hmb  was  a  large  one,  Desault  divided  the  muscles 
in  two  layers ;  he  also  divided  the  skin  by  two  semi-circular 
incisions,  instead  of  making  one  complete  circle,  but,  like 
Petit,  he  divided  the  bone  on  a  level  with  the  highest  section 
of  the  muscles. 

"  The  operation  of  Bell  and  Hey — that  '  with  the  triple 
incision,'  as  the  latter  called  it,  the  skin  and  fascia  being  first 
divided  and  dissected  up  for  a  sufficient  distance,  then  the 
muscle  cut  and  separated  from  the  bone,  and  this  finally 
sawn  through  at  a  still  higher  point — constitutes  in  all  essen- 
tial particulars  the  circular  operation  of  the  present  day. 

"  The  first  flap-operation  appears  to  have  been  suggested 
by  Lowdham,  of  Exeter,  as  described  by  Young,  of  Plymouth, 
in  his  "  Currus  triumphalis  e  terebintho,"  published  in  1679. 
....  Lowdliaui's  and  Young's  operation  was  applied  to  the 
leg,  and  consisted  in  cutting  from  without  inwards  a  long 
flap  of  skin  and  fascia  from  over  the  muscles  of  the  calf. 

"  Verduin,  of  Amsterdam,  in  1696,  and  Sabourin,  ot 
Geneva,  in  1702,  introduced  the  plan  of  forming  a  musculo- 
cutaneous flap  from  the  calf  of  the  leg,  by  transfixion,  and 
attempted  to  control  the  bleeding  by  pressing  this  firmly 
against  the  end  of  the  stump.  Verduin's  flap  was  adopted  by 
Garengeot,  who,  however,  ligatured  the  bleeding  vessels,  and 
thus  perfected  the  ordinary  flap  operation  of  the  leg  as  it  is 
still  often  practised  at  the  present  day, 

"  O'Halloran  (1764),  an  Irish  surgeon,  Ukewise  employed 
this  mode  of  amputation,  but  did  not  close  the  stump  till  the 
flap  was  already  covered  with  granulations. 


264  OPERATIVE    SURGERY. 

"The  earliest  double-flap  amputation  ....  appears  to 
have  been  practised  by  Eavaton,  a  French  surgeon,  about  the 
year  1739.  He  apphed  this  method  of  operating  to  the 
thigh,  making  first  a  circular  incision  down  to  the  bone,  and 
supplementing  this  by  longitudinal  incisions  in  front  and 
behind,  making  thus  two  square,  muscular,  lateral  flaps,  at 
point  of  junction  of  which  the  bone  was  then  divided. 

"  Vermale  modified  and  improved  this  procedure  by 
making  the  flaps  of  a  rounded  or  somewhat  oval  shape, 
and   by  forming  them  by  transfixing  the  limb  with  a  long 

knife   and   cutting  from  within  outwards The   flap 

operation,  in  one  or  other  of  its  forms,  was  soon  adopted  by 
other  surgeons,  and  with  various  modifications  was  finally 
brought  into  ordinary  use  through  the  example  mainly  of 
Liston  and  Guthrie  in  England,  of  Dupuytren,  Roux,  and 
Larrey,  in  France,  and  of  Klein  and  Langenbeck  in  Germany. 
All  the  various  forms  of  amputation  which  have  been  since 
employed  may  be  regarded  as  varieties  of  these  two  principal 
methods,  the  flap  and  the  circular." 

The  introduction  of  anaesthetics  has  materially  altered  the 
details  of  amputation  as  an  operative  procedure.  In  the  days 
before  chloroform,  the  principal  good  quality  which  com- 
mended itself  both  in  tlie  method  and  in  the  operator  was 
rapidity  of  execution.  Time  was  an  essential  element  in  every 
amputation.  The  capacity  of  a  surgeon  was  apt  to  be  gauged 
more  by  the  minutes  he  required  for  the  removal  of  a  leg  than  by 
the  character  of  the  stump  which  resulted  from  the  operation. 

It  thus  happened  that  the  cutting  of  flaps  by  transfixion, 
and  the  selection  of  sites  suited  for  this  method,  were  prominent 
features  in  the  science  and  art  of  amputation  as  taught 
immediately  before  the  introduction  of  ansesthetics. 

In  dealing  with  a  diseased  foot  it  was  considered  advisable 
to  amputate  the  leg  at  the  place  of  election,  for  the  two  con- 
spicuous reasons  that  the  operation  could  be  very  rapidly 
performed,  and  as  the  patient  would  for  the  future  bear 
pressure  upon  the  bent  knee,  the  condition  of  the  stump  was 
of  smaU.  moment.  An  operation  such  as  Syme's  amputation 
would  have  involved  time,  and  would  have  required  con- 
siderable deliberation,  and  its  success  would  have  involved  the 
capacity  of  the  stump  for  bearing  direct  pressure. 


HISTORY   OF   AMPUTATION.  265 

Amputations  were  planned  with  comparatively  little  care. 
The  hmb  had  to  be  "Avhipped  off"  while  the  patient  was 
conscious,  and  the  method  that  permitted  of  its  most  ready 
execution  was  the  best. 

Now  that  time  is  of  comparatively  httle  consequence  in  the 
majority  of  cases,  the  whole  aspect  of  amputation  methods  has 
been  altered.  The  flaps  can  be  cut  with  great  accuracy  and 
dehberation,  and  the  procedure  carried  out  with  the  precision 
of  a  plastic  operation. 

It  has  been  made  evident  that  a  limb  may  be  more  con- 
veniently removed  by  cutting  in  a  steady  manner,  and  upon 
minutely  defined  lines,  than  by  slashing  it  off  by  a  few 
brilliant  and  momentary  passes  of  the  knife. 

The  introduction  of  anaesthetics  has  rendered  possible  such 
admirable  operations  as  Farabeuf  s  amputation  by  an  external 
flap  at  the  place  of  election,  the  subastragaloid  amputations, 
and  the  various  osteo-plastic  methods  of  removing  diseased 
parts. 

The  very  character  of  the  instruments  used  in  amputation 
has  been  altered.  The  long  slender  flashing  blade  of  Fergusson's 
time  is  now  but  seldom  seen.  (Fig.  97.)  Many  amputations 
are  now  best  effected  simply  with  a  large  scalpel. 

The  great  amputating-saw  that  in  skilled  hands  would 
divide  the  femur  in  so  many  feverish  cuts,  is  replaced  by  an 
instrument  which  cuts  more  slowly,  but  at  the  same  time  more 
accurately  and  more  neatly. 

The  improved  methods  of  treating  wounds  and  of  securing 
bleeding  points  have  also  had  much  influence  upon  the 
development  of  the  operation.  Many  procedures  which  now 
yield  admirable  results  would  have  been  almost  unjustifiable 
at  a  time  when  wounds  were  adjusted  with  hempen  sutures, 
and  dressed  with  rags  soaked  in  oil. 

No  one  single  factor  conduces  more  to  the  production  of  a 
perfect  stump  than  healing  by  primary  intention,  or  the  closure 
of  the  incision  without  suppuration. 


266 


CHAPTER    II. 
The  Amputation  Stump. 

The  success  of  any  amputation  or  method  of  amputating 
is  to  be  measured  not  by  the  rapidity  or  brilliancy  with  which 
the  operation  is  performed,  but  rather  by  the  mortahty 
attending  the  procedure,  and  the  quahties  of  the  resulting 
stump. 

The  importance  of  a  sound  stump,  both  as  far  as  it  relates 
to  the  comfort  of  the  patient  and  the  utihty  of  the  mutilated 
hmb,  caimot  be  over-estimated. 

1.  A  good  stump  is  of  regular  outline,  firm,  soHd,  and  in- 
sensitive. The  scar  is  narrow,  regular,  and  clean,  and  lies  in  a 
groove  in  the  integuments  (Figs.  102  and  127). 

The  skin  is  mobile,  except  at  the  site  of  the  cicatrix,  is 
weU  nourished,  and  capable  of  resisting  pressure.  Those 
stiuxips  are  the  best,  so  far  as  the  integumentary  coverings  are 
concerned,  in  which  the  skin  over  the  more  exposed  parts  is 
normally  accustomed  to  pressure.  Such  stumps  are  illustrated 
b}^  those  in  which  the  principal  flap  is  derived  from  the  sole 
of  the  foot,  the  heel,  the  palm  of  the  hand,  the  front  of  the 
knee,  the  back  of  the  elbow. 

The  "inuscles  become  atrophied,  and  their  divided  ex- 
tremities are  found  to  be  embedded  in  a  mass  of  sound  fibrous 
tissue.  Those  whose  functions  are  abolished  are  more  or  less 
entirely  converted,  in  process  of  time,  into  connective  tissue. 
Such  as  retain  any  capacity  for  action,  retain  to  a  correspond- 
ing extent  some  muscular  structure. 

The  divided  hone  becomes  rounded  off,  the  medullary 
canal  is  closed  either  by  bone  or  by  fibrous  tissue.  The 
extremity  becomes  either  atrophied  and  pointed,  or  presents 
an  abnormal  enlargement  due  to  a  development  of  bone  from 
the  periosteum. 

The  new  bone  in  some  stumps  forms  a  button  or  mush- 


THE   AMPUTATION   STUMP,  267 

room-like  extremity  for  the  shaft.  In  other  instances  the  new 
bone  formations  are  scanty  and  spicular,  and  play  the  part  of 
foreign  bodies  in  the  stump. 

The  wliole  shaft  of  the  bone  wastes.  After  an  amputation 
through  the  knee,  the  femoral  condyles  may  entirely  disappear, 
and  in  an  amputation  above  that  joint,  not  only  may  the  shaft 
and  tuberosities  become  evenly  atrophied,  but  this  retrogressive 
change  may  extend  to  the  peivic  bones  of  the  same  side. 

After  a  disarticulation  the  cartilage  left  upon  the  bone 
atro])liiGs,  and  becomes  fibrous,  or  entirely  disappears  in  the 
course  of  years. 

The  nerves  undergo  a  like  atrophic  process.  The  true 
nerve  fibres  disappear  to  a  variable  extent,  and  are  replaced  by 
connective  tissue.  This  change  may  extend  to  the  spinal  cord, 
and  even  to  the  nerve  columns  concerned. 

The  divided  extremities  of  the  nerves  may  become  enlarged 
and  form  considerable  bulbous  terminations.  It  may  be  here 
said,  however,  that  this  condition  is  not  necessarily  associated 
with  tenderness  of  the  stump  (.see  page  268). 

The  collateral  circidation  is  soon  restored  in  the  limb  after 
the  high  division  of  the  main  artery.  That  trunk  in  time 
attains  to  such  dimensions  as  are  demanded  by  the  vascular 
needs  of  the  part.  Some  years  after  an  amputation  at  the  hip 
by  an  anterior  flap,  the  portion  of  the  femoral  artery  left  in 
the  stump  will  probably  be  no  larger  than  the  radial. 

The  wasting  of  the  main  trunk  may  be  attended  by  an 
over-development  of  certain  of  its  branches,  so  that  after  a 
lapse  of  time  the  principal  artery  may  be  difficult  to  identify 
on  dissection. 

2.  The  bad  stump  may  owe  its  evil  properties  to  many 
conditions.  An  amputation  wound  is  liable  to  all  the  ills  and 
misfortunes  which  may  attend  the  progress  of  any  other  ex- 
tensive incision. 

In  dealing  with  this  point  it  is  necessary  to  exclude 
those  diseases  of  stumps  which  depend  upon  an  extension  or 
a  reappearance  of  the  original  malady. 

The  skin  may  be  scanty,  thin,  tightly  drawn,  unduly  and 
unevenly  puckered  and  adherent.  The  vitalit}'  of  the  integu- 
ment may  be  so  debased  that  the  stump  remains  cold  and 
purj^le,  and  liable  to  ulcerative  changes  which  pathologically 


26S  OPERATIVE    SURGERY. 

are  allied  to  chilblains,  and  tlie  superficial  gangrenous  pro- 
cesses incident  to  the  senile. 

On  the  other  hand,  ulceration  of  a  stump  may  appear  to  be 
due  to  such  gross  trophic  changes  that  they  are  rather  to  be 
compared  to  the  bedsores  of  the  paralysed,  or  the  "  perforating 
ulcers  "  of  locomotor  ataxia. 

The  scar  may  remain  weak,  or  become  eczematous,  or  be, 
on  the  other  hand,  excessive,  or  take  on  the  development  of 
warty  growths.  The  chronically  inflamed  and  irritated  cicatrix 
may  become  in  time  the  seat  of  an  epithelioma. 

On  the  skin  may  form  corns  or  under  it  may  develop 
bursEe. 

The  end  of  the  divided  bone  may  necrose,  or  the  shaft 
may  become  inflamed. 

The  stump  may  be  excessively  tender,  and  the  seat  of 
continued  pain.  In  some  instances  the  pam  is  due  to  a  slowly 
progressing  periostitis  or  osteitis.  In  the  greater  number  of 
examples  it  depends  upon  the  compression  of  a  nerve. 

The  nerve  ma}^  be  stretched  over  the  extremity  of  the 
stump,  or  be  exjDOsed  directly  to  pressure,  or  be  the  seat  of 
actual  neuritis.  Its  divided  end  may  be  compressed  b}'^  the 
contraction  of  the  mass  of  fibrous  tissue  in  which  it  is  em- 
bedded, or  be  u-ritated  by  a  spicule  or  projecting  mass  of  new 
bone. 

On  examining  painful  stumps  by  dissection  it  is  common 
to  find  the  ends  of  the  divided  nerves  bulbous.  There  would 
however  appear  to  be  no  essential  or  constant  relation  between 
pain  in  the  stump  and  a  bulbous  enlargement  of  the  nerve  ends. 
Such  enlargements  may  be  found  in  stumps  which  are  insen- 
sitive and  capable  of  bearing  any  reasonable  amount  of 
pressure,  and  ma}''  be  absent  in  cases  of  painfid  stump. 

The  examples  of  painful  stump  of  less  clear  origin  are 
ascribed  to  neuralgia  when  the  patient  is  a  male,  and  to 
hysteria  when  the  patient  is  of  the  opposite  sex. 

One  of  the  most  common  and  most  troublesome  of  bad 
stumps  is  that  loiown  as  the  conical  stump. 

3.  The  Conical  Stump,  or  sugar-loaf  stump,  requires  no 
description.  The  apex  of  the  cone  is  formed  by  the  extremity 
of  the  bone,  which  is  not  infrequently  exposed  and  dead.  The 
real   conical   outline   is  best  seen  in   bad   stumps   following 


THE    AMPUTATION   STUMP. 


269 


Fig.  68. — CONICAL  STUMP  FOLLOWING  CIRCULAB 
AJIPCTATION  OF  THE  THIGH  AND  DUE  TO  RtTRAC- 
TION   OF   THE   POSTERIOR   AND  INTERNAL  MUSCLES. 

(Farabeuf.) 


amputation  through  the  arm  or  thigh,  but  all  ill-covered 
stumps,  such  for  mstance,  as  may  be  left  after  disarticulation 
at  the  knee  or  elbow,  must  be  placed  in  the  present  category, 
although  tlioy  cannot  assume  the  typical  outhne  (Fig.  68). 
The  followmg  are  the  usual  causes  of  the  conical  stump : — 
(a)  Too  short  flaps  or  too  low  division  of  the  bone,  whereby 
the  soft  parts  when 
adjusted  prove  to  be 
so  scanty  that  the 
stump  may  be  con- 
sidered to  be  conical 
from  the  commence- 
ment. 

(6)  The  more  or 
less  extensive  slough- 
ing of  the  flap  or 
the  loss  of  a  con- 
siderable portion  of 
the  soft  parts  by  sup- 
puration. 

(c)  The  retraction  of  the  muscles  after  the  amputation  has 
been  completed.  This  retraction  is  a  very  common  cause  of 
conicity.  A  stump  which  at  the  time  of  the  operation  looked 
round  and  substantial  may,  as  a  result  of  slow  and  progressive 
retraction,  become  in  time  quite  cone-shaped  and  useless. 

This  condition  is  most  usually  met  with  in  amputation 
through  very  muscular  parts  and  in  muscular  subjects.  It  is 
common  in  the  thigh  and  upper  arm,  and  in  the  leg.  In  the 
latter  situation  it  is  due  to  the  unequal  and  excessive 
contraction  of  the  great  muscles  of  the  calf.    (See  also  page  271.) 

Rapid  healing  of  the  wound  is  the  main  opponent  of 
secondary  retraction  of  muscle.  In  most  conical  stumps  the 
heahng  has  been  slow  and  ill-conditioned. 

(d)  Growth  of  the  bone  in  young  subjects.  After  an 
amputation  it  would  appear  that  action  ceases  in  the  epiphyses 
left  in  the  stump.  The  bone  does  not  continue  to  grow  at  the 
same  rate  as  the  corresponding  bone  on  the  opposite  side. 
The  main  stimulus  to  the  epiphysis  is  removed. 

To  this  rule,  however,  there  are  exceptions.  Now  and 
then   the   epiphysis   appears   to   be  at  least  normally  if  not 


270  OPERATIVE    SURGERY. 

unduly  active  after  amputation.  The  shaft  left  in  the  stump 
grows,  the  bone  in  time  tends  to  protrude,  and  a  conical 
stump  is  produced.  This  condition  is  most  often  met  with 
after  amj)utations  through  the  arm  in  quite  young  subjects. 
Growth  does  not  cease  at  the  upper  end  of  the  humerus  until 
about  the  twentieth  year.  The  following  example  illustrates 
this  unusual  form  of  conical  stump :  In  the  case  of  a  boy, 
aged  nine,  I  amputated  the  left  arm,  for  injury,  dividing  the 
bone  just  above  the  insertion  of  the  deltoid  muscle.  The 
wound  healed  without  complication.  So  active,  however, 
was  the  growth  in  the  upper  epiphysis  of  the  humerus  that 
before  the  lad  reached  the  age  of  seventeen  years  the  stump 
had  become  conical  three  times,  and  on  three  occasions  I 
had  to  saw  off  a  not  inconsiderable  portion  of  the  shaft  of 
the  bone,  to  restore  the  proper  outline  of  the  stump. 

A  similar  cause  of  conical  stump  has  been  observed  in 
amputations  of  the  leg  close  to  the  knee  joint.  The  epiphyses 
unduly  active  in  such  a  case  belong  to  the  lower  end  of  the 
femur  and  the  upper  ends  of  the  tibia  and  fibula.  In  these 
parts  of  the  bones  growth  does  not  normally  cease  until  about 
the  twenty-first  year ;  while  the  upper  epiphysis  of  the  fibula 
does  not  join  the  shaft  until  the  twenty-fourth  year. 

4.  Circumstances  affecting  the  Contraction  of  the  Stump 
Tissues. 

In  planning  the  flaps  for  an  amputation  it  is  of  the  first 
importance  that  attention  be  paid  to  the  normal  contractility 
of  the  component  skin  and  muscles. 

(a)  The  skin.  The  contractility  of  the  skin  is  consider- 
able, but  subject  to  much  variation.  It  is  practically  lost  in 
parts  which  have  been  long  distended  or  long  infiltrated. 
This  is  well  seen  in  the  integuments  about  a  white  swelling  of 
a  joint  or  a  chronically  inflamed  part.  The  skin  is  apt  to  be 
loose  in  the  aged  and  in  those  who  have  become  rapidly  thin, 
but  at  the  same  time  it  is  found  to  have  lost  more  or  less 
entirely  its  retractile  qualities. 

It  is  needless  also  to  point  out  the  loss  of  contractility  in 
skin  which  has  become  much  atrophied  or  which  has  been 
long  adherent  to  the  deeper  parts. 

Other  things  being  equal,  the  skin  is  most  contractile  in 
regions  where  it  is  thin,   where   the   subcutaneous   tissue   is 


THU    AMI'UTATION    STUMF.  271 

scanty  in  amount,  wliere  the  integuments  are  not  normally 
connected  with  deep  aponeuroses  or  points  of  bone,  and  where 
it  is  but  little  stretched  in  any  position  of  the  hmb.  These 
regions  are  illustrated  by  the  dorsal  aspect  of  the  wrist,  the 
front  of  the  bend  of  the  elbow,  the  front  of  the  forearm  and 
arm,  the  district  just  above  the  ankle,  and  the  region  of  the 
popliteal  space. 

Contractility  is,  on  the  other  hand,  least  marked  in  parts 
where  the  skin  is  .thick,  where  the  subcutaneous  tissues  are 
considerable,  where  the  soft  parts  are  connected  with  deep 
fasciae  or  points  of  bone,  and  where  the  integument  is  exposed 
to  stretching  in  certain  postures  of  the  limb. 

These  regions  are  illustrated  by  the  palm  of  the  hand  and 
the  sole  of  the  foot,  by  the  dorsal  aspect  of  the  finger  joints, 
by  the  soft  parts  in  front  of  the  knee  and  behind  the  elbow, 
and  by  districts  in  which  the  deposit  of  subcutaneous  fat  is 
considerable. 

Speaking  in  general  terms,  the  average  contractility  of  the 
skin  may  be  represented  by .  one-third  of  the  length  of  any 
given  portion,  that  is  to  say,  if  a  skin  flap  is  required  to  be 
8  cm.  in  length  in  order  to  cover  the  bone,  its  length  before 
its  separation  should  be  12  cm. 

(6)  The  Muscles. — All  muscles,  of  course,  coi. tract  on 
division,  but  the  extent  of  that  contraction  is  subject  to 
remarkable  variations. 

Those  muscles  retract  most  which  are  quite  free  between 
their  points  of  origin  and  insertion,  and  which  are  provided 
with  long  tibres,  such  as  the  sartorius,  gracilis,  and  the 
biceps  humeri. 

These  muscles  may  lose,  according  to  Farabeuf,  as  much  as 
four-fifths  of  their  length  on  division. 

Those  muscles  contract  least  which  are  provided  with 
short  fibres,  as  illustrated  by  the  penniform  and  bipenniform 
muscles — which  are  connected  with  bone  at  the  seat  of  the 
division,  as  is  the  brachialis  anticus,  or  which  are  attached  to 
aponeuroses — as  illustrated  by  the  flexor  muscles  of  the  fore- 
arm just  below  the  elbow  jouit. 

In  a  circular  amputation  at  the  middle  of  the  arm  the 
different  degrees  of  contractility  are  Avell  illustrated  by  the 
biceps  on  the  one  hand  and  the  brachiahs  anticus  and  triceps 


272  OPERATIVE    SURGERY. 

on  the  other.  An  equall}'^  forcible  comparison  is  provided  in 
the  calf,  where  the  contraction  of  the  surface  muscles  is 
measured  against  that  of  the  deep. 

Muscular  contraction  is  influenced  also  by  the  size  of  the 
muscle,  by  the  amount  of  it  left  in  the  flap,  by  the  age  and 
health  of  the  patient,  and  the  degree  of  his  muscular  develop- 
ment. 

It  is  impossible  to  gauge  the  contraction  which  will  take 
place  in  a  young,  vigorous,  and  athletic  man  by  that  which  is 

observed  when  the  same  muscles  are 
divided  in  an  aged,  cachectic,  or  bed- 
ridden subject. 

The  muscles  to  be  divided  may 
have  become  atrophied,  or  may  be 
infiltrated  with  inflammatory  material 
or  by  a  new  growth,  or  msij  have 
already  become  fully  contracted  from 
a  long  continued,  fixed  position  of  the 
limb, 
'i  In  addition  to  the  immediate  con- 

Fig.  69.  —  STUMP  OF  EIGHT    traction  of  a  divided  muscle  there  is 

AEM   AFTER  AMPUTATION  BY  ,  ,  ,  ^  ^.  ,    .    , 

TWO  EQUAL  LATERAL  FLAPS,     also  the  secoudary  retraction,  which 
rTSfl^fEBTLlpTAs    foUows   slowly.      This   secondary  re- 
DRAWN  THE  CICATRIX  TO  THE    tractlou  Is   of  courso   influeuced   by 
the  conditions  already  detailed,  but  it 
depends  probably  to  a  much  greater  extent  upon  the  cir- 
cumstances of  the  heahng  process. 

Stumps  in  which,  at  the  time  of  the  operation,  a  very 
liberal  provision  for  the  covering  of  the  bones  was  made,  may 
become  in  time  conical,  if  the  healing  process  be  ill- 
conditioned  and  much  prolonged. 

The  main  preventive  of  secondary  retraction  of  muscles 
is  rapid  and  sound  healing. 

Considering  the  contractility  of  all  the  soft  parts  together 
(skin  and  muscles)  Farabeuf  lays  down  the  following  rules  : 

1.  The  primary  or  immediate  retraction  of  the  tissues 
forming  a  flap  may  be  represented  by  one-third  of  the  length 
of  that  flap,  i.e.,  if  a  flap  of  10  cm.  is  required  to  cover  the 
bone,  it  should  be  cut  15  cm.  long. 

Additional  length  must  be  given  to  the  flap — 


THE   AMPUTATION   STUMP.  273 

(a)  Wlicn  the  section  of  the  bones  is  large  compared  with 
the  section  of  the  soft  parts — as  in  an  amputation  just  above 
the  wrist  or  through  the  leg  (in  a  thin  subject)  a  little  below 
the  knee-joint. 

(b)  When  secondary  retraction  is  to  be  feared. 

(c)  When  the  amputation  is  performed  at  some  distance 
from  the  root  of  the  segment  of  the  limb  concerned.  In  such 
case  all  the  muscles  in  the  flap  are  cut  at  little  less  than 
full  length.  Thus,  other  things  being  equal,  the  flaps  should 
be  proportionately  longer  in  an  amputation  just  above  the 
wrist  than  in  an  amputation  just  below  the  elbow,  the  same 
muscles  being  involved  in  both  cases. 

2.  The  integumentary  part  of  the  flap  should  always  be 
longer  than  the  nuiscular  part. 

The  effects  of  the  retraction  of  the  tissues  after  operation 
upon  the  outline  of  the  wound  vary  in  different  parts.  Thus 
a  circular  incision  at  the  wrist  becomes  an  elliptical  incision 
with  the  highest  point  posterior,  m  consequence  of  the  undue 
retraction  of  the  dorsal  integuments. 

A  circular  wound  about  the  centre  of  the  forearm  remains 
circular,  since  the  parts  contract  equally. 

A  circular  incision  at  the  elbow  becomes  elliptical  with  the 
highest  point  anterior,  owing  to  the  undue  contraction  of  the 
soft  parts  in  front  of  the  joint, 

A  circular  wound  in  the  thigh  takes  an  elliptical  outline 
with  the  highest  point  postero-internal.  It  has  therefore  been 
said  by  Marcelin  Duval,  "  To  carry  out  the  circular  method  in 
the  thigh,  one  must  practise  the  elliptical  incision." 

The  contraction  of  the  tissues  of  a  flap  may  be  very  un- 
equal, owing  to  local  changes  in  the  part  of  the  limb  involved, 

5.  Circumstances  affecting  the  Vitality  of  the  Stump 
Tissues. 

The  vitality  of  a  stump,  and  as  a  consequence  its  dis- 
position to  heal,  depends  mainly  upon  the  character  of  its 
blood  supply. 

If  a  large  fleshy  or  cutaneous  flap  be  cut  containing  an 
insuflicient  number  of  uninjured  arteries  to  meet  its  nutritive 
needs,  it  is  obvious  that  no  skill  in  operating,  and  no  care  in 
tlie  after-treatment,  can  save  some  portion  of  the  flap  at  least 
from  destruction. 


274  OPERATIVE    SURGERY. 

In  fashioning  the  heel  flap  in  a  Syme's  amputation  at  the 
ankle  a  very  slight  deviation  of  the  knife  will  at  once  deprive 
the  flap  of  one-half  of  its  proper  blood  suppl}^ 

In  like  manner  in  the  amputation  at  the  place  of  election 
in  the  leg  by  Farabeuf's  method,  the  single  external  flap  is 
admirably  well  nourished  so  long  as  the  artery  embedded  in  it 
remains  intact ;  but  if  by  any  unfortunate  movement  of  the 
knife  the  vessel  is  divided  at  the  last  moment  at  the  base  of 
the  flap,  no  skill  can  save  its  tissues  from  some  loss  by 
sloughing. 

Moreover,  a  well-nourished  flap  may  be  rendered  ancemic 
by  the  compression  of  bandages  or  by  its  being  too  tightly 
fixed  to  a  supporting  splint. 

The  same  eft'ects — but  in  less  degree — may  follow  the 
bending  of  the  integuments  over  the  bone.  Such  bending 
may  compress  the  vessels  of  the  flap  to  a  dangerous  degree, 
especially  when  the  part  is  much  drawn  upon  by  tight 
sutures. 

In  considering  this  effect  note  must  be  taken  of  the 
natural  disposition  of  the  parts.  For  example,  after  a  dis- 
articulation at  the  loiee-joint  by  a  long  anterior  flap  the  skin 
is  m  its  normal  position  when  it  is  folded  over  the  femur,  and 
no  undue  compression  of  the  vessels  will  occur. 

But  in  a  disarticulation  at  the  same  place  by  a  single  long 
posterior  flap  the  tissues  of  that  flap  are  so  bent  over  the 
condyles  of  the  bone  as  to  cause  the  contained  vessels  to  be 
very  easily  occluded. 

Undue  traction  upon  a  flap  must  in  almost  every  amputa- 
tion tend  to  diminish  its  blood  supply. 

In  fashioning  skin  flaps,  care  must  be  taken  that  they  are 
not  too  scantily  cut,  and  that  the  skin  itself  is  not  separated 
from  the  subcutaneous  tissues. 

The  blood  supply  of  the  skin — from  the  point  of  view  of 
flap  formation— varies  in  diftercnt  parts  of  a  limb,  and  is  most 
efficient  in  the  region  of  the  joints.  The  largest  skin  flaps 
possible  in  amputation  may  be  cut  from  the  front  of  the  knee 
or  the  back  of  the  elbow.  Flaps  of  corresponding  size  separ- 
ated from  the  segments  of  the  hmbs  above  and  below  these 
joints  would  in  all  probability  perish  from  mal-nutrition. 

Long  tendons  and  loose  aponeuroses  should  not  be  left  in 


THE    AMPUTATION   STUMP.  275 

a  stump.  Their  vitality  is  low,  and  they  show  a  great  dis- 
position to  slough. 

The  bone  in  the  amputation  stump  not  infrequently  be- 
comes necrosed.  This  may  be  due  to  rough  and  rapid  sawing, 
or  to  extensive  damage  to  the  periosteum. 

The  other  circumstances  influencing  the  vitality  of  flaps 
arc  more  or  less  general,  and  need  not  be  (considered  in 
detail. 

Among  them  are  the  health  and  condition  of  the  patient, 
the  state  of  the  limb  previous  to  amputation,  the  manner  in 
which  the  operation  is  conducted,  and  the  treatment  of  the 
wound  carried  out. 

6.  The  Situation  of  the  Cicatrix. 

The  utility  of  a  stump  depends  to  no  small  extent  upon 
the  position  of  the  cicatrix.  It  is  important,  when  possible, 
that  the  cicatrix  should  be  so  placed  as  to  be  the  least 
exposed  to  pressure. 

In  this  connection  it  must  be  borne  in  mind  that  the 
function  of  a  stump  in  the  lower  extremity  is  very  different 
from  that  of  a  stump  in  the  upper  limb.  The  former  should 
be  capable  of  withstandmg  pressure  and  of  bearing  weight 
upon  its  extremity.  The  scar  therefore  will  be  least  well 
placed  when  it  is  "  terminal,"  or  situated  upon  the  point  or 
summit  of  the  stump.  It  will  be  most  conveniently  disposed 
Avhen  it  is  "  lateral,"  or  placed  upon  one  of  the  sides  of  the 
stump. 

On  the  other  hand,  in  the  upper  limb  the  stump  is  not 
required  to  bear  weight  or  to  withstand  pressure  upon  its 
extremity.  The  pressure  will  most  usually  come  upon  the 
sides  or  circumference  of  the  stump.  This  is  seen  in  noting 
the  movements  of  an  artificial  arm — e.g.,  after  an  amputation 
above  the  elbow — when  the  limb  is  passed  in  various 
directions.  As  the  apparatus  is  placed  in  one  or  other 
attitude  the  stump  which  directs  it  will  receive  pressure 
on  its  "sides,"  but  not  upon  its  extremity  or  terminal 
point. 

In  a  general  way  therefore  it  may  be  said  that  the  position 
of  the  cicatrix  which  is  best  adapted  for  stumps  of  the  upper 
limb  is  least  adapted  for  those  of  the  lower. 

Some  stumps  of  course  require  quite  special  support  and 


276 


OPERATIVE    SUBGEBY. 


some   artificial   limbs  can   be  worked  independently  of  any 
assistance  from  tlie  actual  stump  itself". 

If  a  "  peg-leg  "  be  emploj^ed  after  an  amputation  at  the 
place  of  election,  tlie  position  of  the  cicatrix  is  a  matter  of  not 
the  least  importance. 

Amputation  cicatrices  may  be  divided  into  three  classes : 
(a)  Terminal,  Avhen  the  scar  occuj)ies  the  actual  extremity 

of  the  stump  (Fig.  142). 
(6)  Lateral,  when  it  occupies  one  or  more  of  the  sides  of 
the   stump  or  parts   of  its    circumference,  as,  for 
example,    when   the   wound   is   placed   upon   the 
anterior,  or  posterior,  or  internal  surface  of  the 
limb  (Figs.  102,  127,  and  130). 
(c)  Termino-lateral,  when  a  terminal  cicatrix  is  prolonged 
on   to   one   or   more    of    the    sides   of   a   stump 
(Fig.  69). 
The  position  of  the  cicatrix  after  amputation  by  various 
methods  may  be   detailed   as   follows.     In   considering   this 
matter,  however,  the  effects  of  the  retraction  of  the  tissues 
after   operation,   upon   the  outline   of  the   wound,   must   be 
borne  in  mind  (page  270). 


Circular 
Elliptical 


Oval  or  racket 
Single  flap 
Double  flap 


scar  terminal. 

if  oblique,  scar  wholly  lateral ; 
if  nearly  horizontal,  scar  ter- 
minal. 

scar  termino-lateraL 

scar  lateral. 

if  of  equal  size,  scar  terminal ; 
if  of  unequal  size,  scar  lateral. 


277 


CHAPTER    III. 

The  Controlling  of  HyEMORRHAOE  during  the 
Operation. 

Under  this  heading  may  be  considered  (a)  the  use  of  the 
tourniquet,  (b)  the  use  of  Esmarch's  band,  and  (c)  the  employ- 
ment of  digital  compression. 

(a)  The  tourniquet  has  been  the  subject  of  almost  endless 
modifications.  Originally  it  took  the  form  of  a  simple  band 
or  fillet,  which  was  tied  as  tightly  as  possible  around  the  limb, 
above  the  site  of  the  amputation.  Then  came  the  invention 
of  Morel  (1674),  by  which  sticks 
were  introduced  under  the  band, 
and  twisted  round  so  as  to  com- 
press the  limb  as  vigorously  as 
required. 

Following  upon  this  was  the 
admirable  tourniquet  of  Petit 
(1718),  in  the  construction  of 
which  a  metal  scrcAV  was  intro- 
duced, and  in  which  the  principal 
pressure  was  brought  to  bear  upon 
the  main  artery. 

Petit's  instrument,  and  its 
modifications,  represent  one  type 
of  tourniquet  (Fig.  70).  The 
whole  of  the  circumference  of 
the  limb  is  more  or  less  tightly  Fig-  7o.  -  petit's  screw  tourni- 
compressed,  while  localised  press-  ^^^^" 

ure  is  brought  to  bear  upon  the  main  vessel.  This  type  of 
instrument  has  the  advantage  of  being  kept  easily  in  place, 
and  the  disadvantage  of  compressing  all  the  vessels  of  the 
limb,  especially  the  veins.  It  plays  the  part  of  a  very  tightly - 
tied  cord. 


278  OPERATIVE    SUUGEBY. 

The  second  type  of  tourniquet  is  of  later  development.  No 
band  is  emplo3'ed ;  the  whole  instrument  is  of  metal,  and  an 
attempt  is  made  to  limit  the  compression  to  the  main  artery. 

This  form  of  appara- 
tus is  illustrated  by  Sig- 
noroni's  horseshoe  tour- 
niquet (Fig.  71),  and  by 
the  tourniquets  of  Skey, 
Lister,  and  De  Carte. 

These  all  possess  the 

advantasfe    of  not    com- 

pressing  the  entire  limb, 

-WKI.SS  s  Mm^mcATioN  OF  siGNOKONrs     .^^^^  of  leaviug  thc  grcatcr 

part  of  the  circumference 
free,  but  the  disadvantage  of  being  very  easily  displaced  and 
put  out  of  position. 

The  objections  to  all  tourniquets  are  these  :  An  apparatus 
is  required ;  and,  indeed,  to  suit  the  needs  of  all  cases,  many 
different  instruments  are  necessary.  The  compression  is  un- 
inteUigently  employed,  is  apt  to  be  irregularly  applied,  and  to 
be  excessive  and  injurious  in  amount.  During  the  movements 
of  the  limb,  or  of  the  patient,  the  tourniquet  is  very  liable  to 
be  displaced.  Instruments  of  the  Petit  type  have  the  dis- 
advantage of  compressing  the  limb  in  its  entire  circumference. 
However  ingenious  the  pad,  or  however  carefully  it  is  adjusted, 
it  can  scarcely  avoid  compression  of  the  main  vein  (as  in 
the  groin),  as  well  as  the  main  artery.  With  Petit's  instru- 
ment this  is  indeed  inevitable. 

The  tourniquet  has  played  a  very  important  part  in  the 
operation  of  amputation,  but  its  chief  merits  belong  to  the 
past.  It  is  but  little  used  at  the  present  time.  It  was  of 
admirable  service  before  the  days  of  anaesthetics,  when  the 
struggling  patient  had  to  be  firmly  held  and  the  artery  to 
be  compressed  by  main  force,  and  when  the  means  employed 
for  the  securing  of  divided  vessels  were  tedious  and  un- 
couth, 

(b)  Esmarch's  bandage  and  tourniquet  have  enjoyed  a  high 
reputation,  and  have  been  extensively  employed  in  cases  of 
amputation.  The  method  involved  reproduces  that  of  the 
oldest   form   of  tourniquet — the   fillet,    with    the   important 


TOURNIQUETS    IN   AMPUTATION.  279 

difference  that  the  constricting  band  is  elastic,  instead  of  being 
unyielding. 

That  the  band  is  of  great  convenience  to  the  surgeon  is 
obvious  ;  that  it  is  of  material  assistance  to  the  hesitating  and 
nervous  operator  is  also  evident.  Its  advantages  to  the  patient, 
however,  are  not  so  clear. 

Not  a  little  of  the  reputation  attending  the  apparatus  has 
depended  upon  its  fortuitous  association  with  the  attractive 
term  "  bloodless  operation." 

It  has  long  since  been  shown  that,  within  limits,  the  loss  of 
blood  at  an  operation  is  not  the  only  possible  evil,  and  that  a 
perfect  result  does  not  of  necessity  follow  a  bloodless  method. 

The  objections  to  the  tube,  or  band,  are  these : 

In  the  first  place,  if  the  pressure  be  maintained  for  more 
than  a  quite  short  time,  some  temporary  paralysis  of  the 
vasomotor  nerves  of  the  part  follows,  with  the  result  that 
when  the  tourniquet  is  removed  an  unusual  amount  of  oozing 
occurs  from  the  still  dilated  vessels.  General  oozing  is  less 
easy  to  deal  with  than  are  a  few  spurting  arteries  ;  the  after- 
bleeding  may  be  so  considerable  that  the  term  "  bloodless 
method  "  becomes  quite  '-nial-apropos.  Oozing  usually  involves 
much  sponging,  rubbing,  and  washing  of  the  raw  surface,  the 
possible  application  of  some  styptic  solution,  and  the  ex- 
penditure of  not  a  little  time.  "  In  all  cases,"  writes 
MacCormac,  "  its  prolonged  use  materially  increases  the 
subsequent  bleeding  from  the  smaller  vessels  in  the  stump, 
and  often  necessitates  the  application  of  double  or  triple  the 
number  of  ligatures  commonly  employed." 

It  is  needless  to  point  out  that  these  circumstances  militate 
against  primary  healing. 

After  the  sutures  have  been  applied,  and  the  stump  dressed, 
more  oozing  continues  very  often  than  is  to  be  expected  when 
no  constricting  band  has  been  employed. 

In  any  case  the  band  would  appear  to  increase  the  amoimt 
of  venous  haemorrhage. 

In  the  second  place,  Esmarch's  tourniquet,  if  long  applied, 
has  apparently  the  effect  of  hindering  the  healing  process,  and 
this  is  not  improbably  due  to  some  very  superficial  sloughing, 
or  to  an  undue  reaction  following  upon  the  release  of  the 
vessels  from  pressure. 


2S0  OPERATIVE    SURGERY. 

In  the  tliird  place,  the  band,  if  appUed  near  to  the  site  of 
the  amputation,  may  interfere  with  the  retraction  of  the  divided 
muscles,  may  embarrass  the  operator,  and  may  even  slip  off 
during  an  important  stage  of  the  operation. 

In  the  fourth  place,  some  temporary  paralysis  may  follow, 
especially  in  the  arm  and  in  thin  subjects,  owing  to  long  com- 
pression of  the  nerves  of  the  limb ;  and  I  have  been  induced  to 
beheve  that  an  unusual  degree  of  pain  may  attend  the  earlier 
period  of  the  patient's  recover}^. 

It  may  be  added,  finally,  that  the  use  of  Esmarch's 
tourniquet  may  render  the  surgeon  a  little  careless,  and  may 
put  in  jeopard}'"  the  main  vessels  of  a  flap,  which,  if  the  tourni- 
quet were  not  applied,  would  be  approached  with  especial  care. 

In  some  cases,  without  doubt,  this  elastic  tourniquet  is 
very  useful.  It  is  simple  and  handy,  is  readily  applied,  and 
retains  its  position.  Moreover,  it  controls  all  bleeding  com- 
pletely. It  has  been  of  especial  service  in  amputations  at  the 
hip  and  shoulder  joints,  and  its  application  is  described  m 
the  sections  dealing  with  these  operations. 

It  is  useful,  also,  in  instances  where  the  surgeon  has  to 
operate  with  little  assistance,  or,  at  least,  without  competent 
help,  and  in  some  cases  of  very  muscular  or  very  corpulent 
subjects, 

I  would  venture  to  think,  however,  that  its  use  should  be 
limited  to  exceptional  cases,  and  that  it  should  not  be  regarded 
as  a  necessary  appendage  to  all  amputations. 

The  elastic  bandage  employed  with  Esmarch's  tourniquet  is 
of  somewhat  doubtful  value. 

It  is  true  that  it  empties  the  limb  of  blood,  and  forces  it 
back  into  the  general  circulation.  The  extremity  is  rendered 
amemic,  and  the  blood  that  would  have  been  lost  with  the 
limb,  if  no  bandage  was  used,  is  saved  to  the  patient. 

I  am  not  aware  that  this  economy  in  blood  has  been  proved 
to  be  of  substantial  worth.  Parts  which  have  been  long 
rendered  ansemic  are  not  placed  in  the  best  condition  for 
ensuring  primary  healing ;  and,  moreover,  if  the  forcing  of  a 
quantity  of  blood  into  the  general  circulation  increases  the 
blood  pressure  at  the  time,  the  possibility  of  an  abnormal 
amount  of  oozing  has  to  be  anticipated.  If  a  patient  cannot 
afford  to  lose  the  amount  of  blood  which  Avill  be  lost  in  an 


DIGITAL    rRESSUME    IN   AMPUTATION.  281 

anipiitatecl  limb,  it  may  be  a  question  as  to  how  far  the  ampu- 
tation itself  is  justifiable. 

The  bandage  may  have  the  effect  of  displacing  clots.  It 
should  certainly  not  be  applied  to  a  limb  the  seat  of  suppura- 
tion or  gangrene  ;  and  in  the  case  of  malignant  growth,  the 
"  emptying "  of  the  extremity  by  means  of  elastic  pressure, 
and  the  actual  compression  of  the  growth  itself,  may  be 
attended  by  no  little  risk. 

I  have  long  since  entirely  abandoned  the  use  of  the 
bandage;  and  it  appears  to  me  that  the  end  aimed  at — so 
far  as  the  saving  of  blood  is  concerned  —  may  be  more 
efficiently  and  more  safely  attained  by  keeping  the  limb 
elevated  for  some  little  time  before  the  main  vessels  are 
compressed  and  the  knife  introduced. 

(c)  Digital  compression  of  the  main  artery  is  the  best 
method  of  controlling  bleeding  during  an  amputation,  and 
should  be  employed  whenever  possible. 

It  requires  a  skilled  and  strong-handed  assistant.  The 
pressure  upon  the  artery  can  be  well  localised,  well  regulated, 
and  rendered  precise. 

The  main  vein  need  not  be  included  in  the  compression,  as 
in  the  case  of  the  femoral  vessels  at  the  groin.  The  brachial 
artery,  however,  could  scarcely  be  occluded  without  at  the 
same  time  obliterating  the  lumina  of  the  companion  veins. 

The  pressure  need  not  be  applied  for  a  moment  longer  than 
is  required,  and  can  be  at  once  relaxed,  and  at  all  times 
accurately  controlled.  It  is  limited  to  the  part  required ;  there 
is  no  general  compression  of  the  soft  tissues,  and  no  injurious 
compression  of  nerves. 

The  fingers  of  a  skilled  assistant  are  more  reliable  than 
any  tourniquet,  and  are  less  likely  to  shift  their  position. 

They  have  that  intelligent  hold  of  the  artery  which  the 
most  ingenious  tourniquet  must  of  course  lack. 

Special  means  of  controlling  htemorrhage  may  be  required 
during  disarticulations  at  the  hip  and  shoulder.  These 
measures  are  considered  in  the  sections  dealing  with  those 
operations. 

Putting  aside  these  particular  circumstances,  it  may  be 
said,  in  general  terms,  that  digital  compression  should  be 
employed  during  all  amputations. 


282  OPERATIVE    SURGE  BY. 

If  the  artery  be  well  controlled,  the  method  has  the  principal 
claim  to  be  termed  "  bloodless,"  especially  when  the  operation 
is  of  some  duration. 

It  should  be  remembered  that  the  question  of  controlling 
bleeding  during  amputation  has  been  much  modified  during 
recent  years. 

In  the  first  place,  the  introduction  of  pressure  forceps, 
which  can  close  any  vessel  in  a  moment,  has  very  greatl}' 
simplified  the  means  for  arresting  haemorrhage. 

In  the  next  place,  amputation  methods  have  altered. 
Limbs  are  not  slashed  off,  and  main  vessels  sliced  open,  as 
was  a  common  practice  some  fifty  years  ago. 

Many  flaps  are  now  so  carefully  and  methodically  cut 
that  each  vessel  as  it  is  divided  is  secured  by  pressure  forceps. 

In  any  case,  the  main  vessels  are  clamped  as  soon  as  they 
are  severed.  In  some  amputations  it  is  possible  for  these 
trunks  to  be  secured  before  they  are  divided. 

The  assistant  who  controls  the  arter}^  must  have  anatomical 
knowledge  and  strong  hands. 

In  the  upper  hmb,  in  children,  in  aged  and  emaciated 
subjects,  the  compression  can  be  easil}-  kept  up. 

In  the  lower  limb,  m  the  corpulent,  and,  above  all,  in  the 
very  muscular,  the  pressure  is  not  so  readily  maintained. 

In  such  cases,  and  in  instances  where  the  amputation  in- 
volves much  time,  two  assistants  are  requu-ed,  or  aid  may  be 
given  by  means  of  a  screw  tourniquet  or  weight,  which  can 
be  adjusted  upon  the  assistant's  fingers. 

In  all  amputations  below  the  hip  and  the  shoulder  the 
compression  is  concerned  only  with  the  femoral  arter}''  against 
the  OS  pubis,  and  the  brachial  artery  against  the  humerus. 


283 


CHAPTER    IV. 

The  Instruments  required  in  Amputation. 

The  actual  instruments  needed  in  each  amputation  are 
enumerated  in  their  respective  sections. 

The  Amputating  Knife  must  necessarily  vary  according  to 
the  character  of  the  operation.  The  great  alterations  made  in 
recent  years  in  the  mode  of  performing  amputations  have  had 
an  equally  pronounced  effect  upon  the  chief  instrument.  The 
enormous  knives  employed  some  thirty  or  forty  years  ago 
have  ceased  to  be  used.  Such  a  knife  is  depicted  in  Fig.  97, 
from  Fergusson's  "  Practical  Surgery."  The  author,  in  his 
description  of  the  figure,  remarks :  "  The  knife,  in  my  opinion, 
the  artist  has  represented  a  httle  too  long ;"  but  in  the  same 
work  knives  of  a  proportionate  length  are  depicted  without 
comment.  For  an  amputation  at  the  hip-joint  in  Fergusson's 
time  a  knife  with  a  cutting  edge  of  from  twelve  to  fourteen 
inches  was  employed.  At  the  present  day  that  operation  is 
commonly  effected  with  a  knife  no  larger  than  the  instrument 
used  for  excising  a  breast. 

A  good  amputating-knife  should  possess  the  following 
characters : — The  handle  should  be  large  and  strong  and  from 
four  and  a  half  to  five  inches  in  length.  Its  sides  should  be 
flat  and  its  edges  cut  square.  Its  surfaces  should  be  well 
roughened. 

With  regard  to  the  length  of  the  blade,  it  must  be  remem- 
bered that,  when  force  and  precision  are  required,  the  blade 
must  be  short  and  the  handle  large  and  strong.  This  is  weU 
illustrated  by  Syme's  amputation,  for  which  operation  no  in- 
strument is  better  suited  than  an  old  resection-knife,  the 
blade  of  which  has  been  shortened  and  narrowed  by  repeated 
•'  settings," 

For  transfixion  operations  the  length  of  the  blade  should 


284  OPERATIVE    SURGERY. 

be  equal  to  that  of  one  diameter  and  a  half  of  the  limb,  and 
the  same  rule  applies  roughly  to  the  knife  required  for  the 
circular  ojjeration. 

Over  these  long  blades  the  operator  has  little  control,  as 
■will  be  shown  if  he  attempt  to  complete  a  transfixion  or  cir- 
cular amputation  with  the  long  knife  used  at  the  commence- 
ment of  the  operation. 

In  performing  an  amputation  at  the  hip  by  antero-posterior 
Haps  cut  by  transfixion,  the  point  of  the  knife  has  been  thrust 
into  the  femur  and  broken  against  that  bone,  and  has  found 
its  Avay  into  the  th}Toid  foramen,  into  the  scrotum,  and  into 
the  thigh  of  the  opposite  side. 

In  a  good  amputating-knife  the  blade  is  light  and 
narrow,  and  the  back  not  too  heavy.  The  point  of  the 
knife  is  nearly  lancet-shaped,  and  the  very  tip  corresponds 
to  the  extremity  of  a  line  dra^vn  along  the  long  axis  of 
the  knife  and  through  the  centre  of  the  blade  (Fig.  72). 
It  is  convenient  in  transfixion  am2:)utations  that  the 
extremity  of  the  steel  should   be  double-edged  (in  Fig.  72 


Fig.    72. — TRANSFIXION    AMPUTATION   KNIFE. 

The  double  edge  extends  from  the  point  to  A.     The  dotted  line  indicates  the  centre 

of  the  blade. 

as  far  as  a).  There  is  no  prominent  "  heel "  to  the  knife  to 
engage  the  tissues  and  embarrass  the  surgeon's  fingers.  The 
point  is  not  too  fragile. 

In  the  smaller  knives — such  as  are  adapted  for  cutting 
flaps  from  without  inwards — the  point  may  be  a  little  nearer 
to  the  dorsum  than  to  the  cutting  edge,  and  the  edge  itself 
may  be  a  little  rounded  (Fig.  74). 


Fig.  73.— AXIPUiATION    KNIFK    WITH    EVKKV    BAD    (iUAI-ITY. 

Fig.  73  shows  an  amputating-knife  with  almost  every  bad 
quality — a  long  knife  with  a  small,  weak,  smooth  handle ;  a 


INSTRUMENTS   FOR    AMPUTATION.  2b5 

blade  with  a  heavy  back,  a  projecting  heel,  and  a  tapering  and 
fraq'ile  point. 

The  instrument  styled  in  instrument-makers'  catalogues 
"  a  metacarpal  knife,"  may  be  taken  to  represent  the  worst 
form  of  knife  that  could  (within  reasonable  limits)  be  used  for 
auiputathig  a  finger  at  a  metacarpal  joint  or  for  removing 
a  metacarpal  bone. 

The  immense  broad-bladed  knives  figured  by  some  authors 
as  adapted  for  amputation  by  the  circular  method  belong  to 
a  past  age. 

The  catlin,  or  double-edged  knife,  has  now  fallen  into 
disuse.  No  such  instrument  is  required  to  divide  the  soft 
parts  between  the  tibia  and  fibula.  The  knife  is  not  only 
quite  unnecessary  in  any  amputation  of  the  leg,  but  in  the 
hands  of  the  inexperienced  is  dangerous. 

A  useful  instrument  in  all  amputations  is  a  good  stout 
scalpel  with  a  substantial  handle. 

The  Amputating-saw  should  be  broad  and  long  in  the 
blade  and  have  fine  teeth.  The  blade  is  about  ten  inches 
in  length,  and  two  and  a  half  inches  in  width.  Those 
with  movable  backs  are  the  most  convenient,  and  enable 
the  sawing  edge  to  be  reduced  to  the  narrowest  possible 
dimensions. 

The  bow  saw,  or  Butcher's  saw,  is  best  adapted  for  ampu- 
tations    in    which     a 
curved  or  oblique  di- 
vision   of   a    bone    is 
desired. 

^r  .  .  Fig.    74. — AMPUTATION    KNIFE    USED    FOR    CUTTING 

Many       retractors  flaps  from  without  inwards. 

have  been  devised  for 

the  purpose  of  protecting  the  soft  parts  during  the  aj^plication 
of  the  saw.  The  simple  Imen  two-tailed  retractor  answers 
well  enough.  The  fingers  of  one  or  more  intelligent  assist- 
ants answer  better.  A  three-tailed  linen  retractor  may 
be  used  in  amputations  through  the  leg  and  the  forearm. 
Three  ivory  spatulce  placed  close  to  the  bone,  and  made  to 
cross  one  another  in  the  form  of  a  triangle,  represent  an  ad- 
mirable retractor. 

The  other  instruments  used  call  for  no  especial  com- 
ment. 


286 


OPERATIVE    SUBGEBY. 


The  following  is  the  list  of  instruments  whicli  may  be 
required  in  the  performing  of  an  amputation : — 


Tourniquet. 

Amputating  Knives. 

Stout  Eesecticij  Knives. 

Scalpels. 

Saws. 

Lion  Forceps. 

Bone  Forceps. 

Periosteal  Elevators. 

Linen  Retractors. 

Ivory  Spatulse. 


Volkmann's  Spoon. 
Gouge. 

Dissecting  and  Artery  Forceps. 
Pressure  Forceps. 
Tenaculum. 

Scissors,  Probe,  Straight  Needles, 
Ligatures,  Sutures,  Dressings. 
Irrigator. 

Kidney-shaped  Eeceiver. 
Splint  or  Support  for  the  Stump, 


CHAPTER    V. 
Methods  of  Performing  Amputation. 

The  following  are  the  principal  procedures  in  amputation : — 

1.  The  Circular  Method. 

2.  The  Modified  Circular  Method. 

3.  The  Elliptical  Method. 

4.  The  Oval  or  Racket  Amputation. 

5.  The  Amputation  by  Flaps. 

1.  The  Circular  Method. — In  this  method  of  amputation 
the  soft  parts  are  divided  by  a  series  of  circular  cuts,  made 
from  the  skin  down  to  the  bone.  The  tissues  are  not  divided 
by  one  sweep  from  integument  to  periosteum,  but  by  successive 
cuts,  in  such  a  way  that  the  skin  and  the  layers  of  muscle  are 
severed  at  different  levels.  The  history  of  this  operation  has 
already  been  alluded  to  (page  262). 

Two  forms  of  circular  amputation  are  practised  at  the 
present  day.  They  are  identical  in  principle,  and  their  differ- 
ences, such  as  they  are,  depend  upon  anatomical  features,  and 
are  indeed  influenced  only  by  locality. 

A.  The  ordinary  circular  amputation — the  amputation 
circidaire  infundibuliforme  of  the  French — is  illustrated  by 
an  amputation  through  the  arm  or  thigh.  In  these  parts  the 
bone  is  more  or  less  evenly  surrounded  by  thick  muscles. 
After  each  circular  cut  the  soft  tissues  are  allowed  to  retract, 
or  are  retracted,  before  a  second  sweep  is  made  with  the  knife. 
The  result  is  that  the  wound  becomes  funnel-shaped;  the 
edge  of  the  fimnel  is  formed  by  the  divided  skin ;  the  apex 
of  the  funnel,  or  infundibulum,  by  the  divided  bone. 

In  performing  a  circular  amputation  the  surgeon  stands  to 
the  right-hand  side  of  the  limb  to  be  removed,  i.e.,  to  the  outer 
side  of  the  right  upper  or  right  lower  Hmb,  and  to  the  inner 
side  of  the  left  limbs.  The  operator  is  thus  able  to  grasp  the 
limb  above  the  site  of  the  amputation  with  his  left  hand.     In 


288  OPERATIVE    SUBGEBY, 

removing  the  left  arm  it  may  be  more  convenient  to  stand  to 
the  outer  side  of  the  extremity. 

The  precise  position  of  the  circular  incision  below  the  level 
of  the  future  saw-cut  must  vary  with  the  site  of  the  amputa- 
tion and  the  condition  of  the  limb.  It  is  indicated  in  the 
descriptions  of  the  particular  amputations. 

The  general  method  of  performing  the  operation  may  be 
illustrated  by  an  amj^utation  of  the  thigh. 

The  surgeon  grasj^s  the  limb  above  the  site  of  the  incision 
with  the  left  hand  and  retracts  the  skin. 

In  this  retraction  he  should  be  aided  throughout  the 
operation  by  an  assistant,  who  draws  up  the  soft  parts  both 
before  and  after  division  with  both  hands,  one  applied  to  either 
side  of  the  limb.  In  this  way  a  much  more  even  and  com- 
plete retraction  is  obtained  than  is  possible  if  the  surgeon 
relies  upon  his  left  hand  alone. 

Grasping  the  knife  in  the  full  hand — as  he  would  hold  a 
pruning-knife — the  operator  passes  his  arm  beneath  the  limb 
and  brings  the  knife  over  its  upper  surface.  The  incision  is 
commenced  with  the  heel  of  the  blade,  while  the  point  is 
directed  towards  the  operator's  feet.  The  cut  should  begin 
well  upon  the  outer  side  of  the  thigh.  To  facilitate  this  an 
assistant  should  rotate  the  limb  inwards  to  its  utmost. 

In  drawing  the  knife  round  the  limb  the  surgeon  cuts  from 
the  heel  of  the  knife  to  the  point.  As  the  blade  passes  round 
the  thigh  the  assistant  who  holds  the  leg  rotates  the  extremity 
outAvards,  so  as  to  make  the  skin  (as  it  were)  meet  the  surgeon's 
knife. 

The  incision  can  be  made  to  traverse  two-thirds  or  more 
of  the  circumference  of  the  thigh  in  one  sweep  and  without 
the  hold  upon  the  knife  being  altered.  The  remaining  part 
of  the  circular  wound  is  completed  by  a  separate  cut  made  in 
the  opposite  direction,  i.e.,  by  cutting  from  the  commencement 
of  the  first  incision  to  the  point  where  it  ended.  While 
effecting  this  the  limb  is  once  more  fully  rotated  inwards. 

Some  surgeons  appear  to  consider  it  important  that  the 
circular  cut  should  he  made  in  one  sweep  of  the  knife.  To 
effect  this  the  surgeon  has  to  crouch  down,  or  even — according 
to  the  advice  of  some — to  rest  upon  one  knee  when  commencing 
the  incision     During  the   passage  of  the  knife  around  the 


METHODS    OF   AMPUTATING.  289 

thigh,  the  operator  has  to  alter  his  grasp  of  the  handle.  This 
single  circular  sweep  may  be  admirable  as  a  demonstration  of 
sleight  of  hand,  and  may  be  considered  to  justify  the  some- 
what ridiculous  attitudes  assumed  by  the  performer.  As  a 
surgical  procedure  it  is  not  to  be  commended.  The  incision 
so  effected  is  usually  imperfectly  made,  and  is  almost  invariably 
of  unequal  depth,  for  in  the  terminal  part  of  the  circle  the/ 
surgeon  has  a  diminished  control  over  the  blade. 

From  repeated  experiments,  I  think  I  may  say  that  a 
circular  division  of  muscles,  in  a  large  limb,  made  by  one 
sweep  of  the  knife  is  invariably  defective  and  unequal. 

In  dividing  the  integuments,  the  blade  should  be  kept 
throughout  absolutely  perpendicular  to  the  surface,  and  should 
extend  no  deeper  than  the  deep  fascia. 

The  next  step  in  the  operation  consists  in  freeing  the 
integuments  so  that  they  can  be  further  retracted. 

While  the  assistant,  directed  and  aided  by  the  surgeon's 
left  hand,  draws  up  the  divided  skin  fully  and  evenly,  the 
knife  is  passed  round  the  limb  close  to  the  edge  of  the  skin, 
so  as  to  divide  all  bands  connecting  the  integument  with  the 
deeper  tissues.  Especial  and  distinct  bands  are  usually  found 
in  the  lines  of  the  main  inter-muscular  septa. 

In  effecting  this  freeing  of  the  skin,  the  knife  must 
throughout  be  kept  perpendicular  to  the  surface.  It  is  un- 
desirable to  pass  the  blade  obliquely  beneath  the  integument 
for  the  purpose  of  dividing  its  connections.  Such  a  plan  does 
not  hasten  the  retraction,  nor  make  it  more  complete.  It 
tends  to  render  it  uneven,  and  to  damage  the  future  skin- 
covering  of  the  stump.  In  the  ordinary  circular  amputation 
the  skin  is  not  dissected  up. 

When  the  retraction  of  the  skin  is  complete,  the  muscles 
should  be  laid  bare  and  be  covered  only  by  the  deep 
fascia. 

The  knife  is  now  passed  through  the  superficial  muscles 
precisely  in  the  same  way  as  it  was  made  to  traverse  the 
skin.  The  blade  is  kept  close  to  the  divided  mteguments, 
and  still  quite  perpendicular  to  the  surface.  The  soft  parts 
are  fully  and  evenly  retracted,  and  the  Hmb  is  rotated  to  meet 
•the  knife  in  the  manner  already  described. 

The  divided  tissues  are  again  well  and  regularly  retracted, 


290 


OPERATIVE    SURGERY. 


and  the  knife  by  a  third  circular  sweep  passes  through  the 
deeper  muscles  and  reaches  the  bone. 

A  fourth  incision  may  be  needed  to  fully  clear  the  bone 
of  muscle  tissue,  and  this  can  best  be  effected  by  a  stout 
scalpel. 

Throughout  the  operation  care  must  be  taken  that  the 


Fig.  7o. — CIRCUL.4R  AiiPijiATiON  «  la  manehette. 

retraction  is  even — or  is  modified  as  required — and  that  the 
knife  is  held  always  with  a  perpendicular  blade. 

The  formation  of  a  periosteal  flap  is  considered  below 
(page  305). 

The  severed  muscles  now  form  a  cone,  the  apex  of  which 
is  at  the  bone  bared  for  the  saw. 

The  retractor  is  applied  and  the  bone  sawn  through. 

In  the  description  which  follows,  illustrations  of  the 
ordinary  circular  amputation  are  afforded  by  an  amputation 
of  the  arm  (page  375),  and  an  amputation  of  the  thigh  (page 
514). 


METHODS    OF   AMPUTATING.  291 

•B.  The  circular  amputation  a  la  Tnanchette  is  adapted  for 
parts  where  the  covering  of  the  bones  is  scanty  and  is  com- 
posed of  irregular  tissues.  Such  a  region  is  best  illustrated  by 
the  wrist,  where  the  bones  are  surrounded  by  many  tendons, 
and  where  muscular  tissue  is  scanty  and  unevenly  disposed. 

In  this  method  of  amputating,  the  skin  and  subcutaneous 
tissues  are  dissected  up  in  the  form  of  a  cufF,  or  Tnanchette, 
and  are  turned  back  like  the  cuff  of  a  coat. 

The  skin  is  divided,  as  in  the  previous  operation,  by  a 
circular  incision,  and  is  then,  together  with  the  subcutaneous 
tissues,  turned  back  as  shown  in  Fig.  75.  The  turning  back 
of  this  cuff  is  mainly  effected  by  the  lingers  of  the  surgeon's 
left  hand.  The  skin  is  freed  by  the  knife,  which  should  always 
be  held  perpendicular  to  the  surface.  The  cuff  is  not  dismcted 
up.  It  is  gently  freed  and  turned  up.  If  the  knife  be  passed 
obliquely  beneath  the  skin  which  has  to  be  everted,  it  is  apt  to 
be  needlessly  damaged. 

The  cuff  must  be  even  and  regular,  and  of  a  size  pre- 
viously determined  upon. 

The  soft  parts  are  then  divided  by  a  circular  sweep,  with 
the  knife  at  the  level  of  the  retracted  and  everted  skin. 

But  one  such  incision  will  probably  be  necessary. 

It  is  only  about  the  wrist  or  the  lower  part  of  the  fore- 
arm that  a  real  cuff'  of  skin  can  be  formed. 

In  the  arm  or  the  thigh  of  thin  and  wasted  subjects  the 
formation  of  a  "cuff"  is  possible,  but  should  not  be  practised, 
inasmuch  as  it  involves  a  needless  disturbance  and  damaging 
of  the  integuments  which  will  cover  the  future  stump. 

In  the  lower  part  of  the  leg,  in  the  region  of  the  ankle, 
a  manchette  may  be  formed  in  thin  subjects,  but  it  is  not 
easy  to  effect,  and  should  not  be  carried  out,  for  the  reasons 
already  mentioned.  The  difficulty  of  retracting  the  skin  in 
this  region  is  usually  met  by  making  one  or  more  vertical 
incisions  in  the  integument  in  addition  to  the  regular  circular 
incision. 

The  present  variety  of  the  circular  amputation  is  therefore 
practically  limited  to  amputations  through  the  wi'ist  or  lower 
part  of  the  fore-arm,  and  is  illustrated,  in  the  account  which 
follows,  by  the  latter  operation  (page  358). 

The  two  forms  of  circular  amputation  may  be  to  some 


292  OPERATIVE    SURGERY. 

extent  combined,  a  cuff  of"  skin  being  turned  up  upon  one 
aspect  of  the  limb  and  the  integuments  simply  retracted  upon 
the  other.  This  is  illustrated  by  the  circular  amputation  of 
the  leg  at  the  place  of  election  (page  485). 

In  order  to  allow  for  unequal  retraction  of  the  skm  in 
some  parts,  the  circular  incision  may  have  to  be  obliquel}^ 
placed.  It  ceases,  however,  to  be  oblique  when  the  integu- 
ments have  been  allowed  to  retract.  An  illustration  of  this  is  af- 
forded b}'  the  circular  amputation  at  the  elbow-joint  (page  366). 

2.  The  Modified  Circular  Method.  —  Three  important 
modifications  need  to  be  described :  (a)  In  addition  to  the 
circular  cut  through  the  integuments,  a  vertical  incision  is 
made  to  join  the  original  wound.  The  skin  on  either  side  of 
this  vertical  cut.  and  at  the  points  where  the  cut  joins  the 
circle,  is  then  reflected  in  the  form  of  two  imperfect  skin  flaps. 

This  modification  is  illustrated  by  one  form  of  supra- 
malleolar amputation  (page  466). 

(b)  Two  vertical  incisions  are  made  to  join  the  circular 
wound.  By  this  use  of  the  knife,  two  square  skin  flaps  can 
be  dissected  up,  and  the  muscles,  when  exposed,  can  be 
divided  b}^  a  circular  sweep  of  the  knife. 

This  plan  is  also  described  among  the  supra-malleolar 
amputations. 

(c)  The  modification  suggested  by  Listen,  and  extensively 
practised  by  Syme — with  whose  name  the  method  is  asso- 
ciated— is  strongly  recommended  by  many  surgeons  of  the 
present  day.  Two  very  short  flaps,  of  semi-lunar  outline,  and 
of  equal  width  and  length,  are  dissected  up.  They  are  com- 
posed simply  of  the  skin  and  the  subcutaneous  tissues,  and 
consist  of  little  more  than  curved  incisions  made  across 
opposite  surfaces  of  the  limb,  each  being  equal  to  one-half  of 
the  circumference  of  the  limb. 

The  skin  be3'ond  the  bases  of  the  little  flaps  is  then  re- 
tracted as  a  whole,  just  as  in  the  usual  circular  amputation. 
When  the  retraction  has  been  carried  to  a  sufficient  extent, 
the  muscles  are  divided  by  circular  incisions  in  the  usual 
way.  This  method  is  illustrated  by  an  amputation  of  the 
thigh  (page  515). 

3.  The  Elliptical  Method. — This  operation  was  adopted  by 
Sharpe,  of  Guy's  Hospital,  as  an  improvement  on  the  circular 


METHODS    OF   AMPUTATING.  29:^ 

method,  in  the  middle  of  the  last  century.  French  surgeons 
attribute  the  operation  to  Soupart,  of  Liege  (1847),  and  style 
it  la  methode  de  Soupart.  It  is  sometimes  described  as  a 
variety  of  the  oval  method.  It  occupies  an  intermediate 
position  betv/een  the  circular  operation  and  the  amputation 
by  a  single  flap. 

The  incision  in  the  skin  is  elliptical  or  lozenge-shaped 
{le  mode  lof^angique).  The  position  and  inclination  of  the 
ellipse  vary  according  to  the  site  of  the  amputation,  and 
have  to  be  carefully  estimated  (see  Disarticulations  at  the 
Elbow-joint).  The  skin  and  subcutaneous  tissues  are  then 
retracted,  by  gliding,  as  in  one  amputation  at  the  wrist  (page 
348),  or  by  the  turning  up  of  a  cuff,  as  in  the  disarticulation 
at  the  elbow  by  a  posterior  ellipse  (page  368),  or  by  the 
separation  of  a  definite  flap,  as  in  Guyon's  supra-malleolar 
amputation  (page  464). 

The  muscles  are  usually  divided  as  in  the  circular  opera- 
tion. They  may  be,  however,  cut  in  part  by  transfixion,  as  in 
the  disarticulation  at  the  elbow-joint  by  an  anterior  ellipse. 

The  elhptical  method  is  well  adapted  for  amjDUtations 
through  certain  joints,  and  is  illustrated  in  the  following 
sections  by  the  operations  just  alluded  to, 

4.  The  Oval  or  Racket  Method. — The  oval  operation,  or 
the  method  of  Scoutetten,  was  definitely  formulated  by  that 
surgeon  in  1827,  The  skin  incision  takes  the  form  of  an 
oval  with  one  end  pointed,  or  of  an  isosceles  triangle  rounded 
at  its  base.  The  edges  of  the  resulting  wound  are  united  in 
its  long  axis.  The  soft  parts  beneath  the  skin  are  divided 
down  to  the  bone  by  cutting  from  without  inwards.  This 
operation  is  illustrated  on  a  small  scale  by  some  amputations 
at  the  joints  of  the  fingers  and  toes,  and  on  a  larger  scale  by 
Guthrie's  amputation  of  the  arm  just  below  the  tuberosities  of 
the  humerus  (page  381). 

A  modification  of  the  oval  method  is  accredited  to  Mal- 
gaigne  (1837).  To  obtain  a  better  exposure  of  a  joint  without 
loss  of  substance,  and  to  afford  a  better  coverinsf  for  the 
bone  in  the  upper  part  of  the  wound,  Malgaigno  extended  a 
longitudinal  cut  from  the  apex  of  the  oval,  producing  thus 
Vincision  en  raquette,  the  longitudmal  wound  forming  the 
handle  of  the  "  racket."     This  incision  is  also  called  by  the 


294  OPERATIVE    SURGERY. 

French  I'incision  en  crouinere,  and  in  some  amputations  it 
certainl}^  more  closely  conforms  to  the  outline  of  a  "  crupper" 
than  to  that  of  a  "  racket." 

In  this  category  is  placed  also  the  T-shaped  incision — an 
incision  formed  of  a  circular  cut  joined  by  a  longitudinal  one. 
The  racket,  crupper,  and  T-shaped  incisions  are  best  illus- 
trated by  disarticulations  at  the  metacarpo-phalangeal  and 
metatarso-phalangeal  lines  of  joints  (Figs.  82  and  100). 

Amputation  by  the  racket  incision  is  also  illustrated  by 
certain  disarticulations  at  the  shoulder  and  at  the  hip 
joints. 

5.  The  Flap  Method. — The  methods  of  performing  am- 
putation by  means  of  flaj)s  are  numerous  and  varied,  and 
have  been  subjected  from  time  to  time  to  so  many  modi- 
fications and  re-modifications  that  a  systematic  classification 
of  flap  methods  is  scarcely  possible. 

A.  Skin  Flaps  and  Muscle  Flaps. — Any  flap  or  flaps  may 
be  composed  of  the  integuments  only,  or  of  the  integuments 
and  the  subjacent  muscular  tissue.  Some  difference  of  opinion 
has  existed  as  to  the  merits  of  skin  flaps  and  muscle  flaps. 

In  every  flap  the  skin  must  be  cut  longer  than  the  muscle 
tissue.  A  flap  containing  too  much  muscular  tissue  is  un- 
wieldy ;  it  is  difficult  to  adjust,  and  the  muscle  is  certain  to 
protrude.  In  endeavouring  to  bring  the  edges  of  the  skin 
together,  undue  strain  is  apt  to  be  placed  upon  the  sutures. 
Much  of  the  muscle  tissue,  being  far  removed  from  its  blood 
supply,  may  slough.  If,  however,  the  part  heals  well,  the 
resulting  stump  is  firm  and  well-rounded,  and  the  end  of  the 
bone  is  well  covered, 

A  flap  composed  of  skin  only  is  very  apt  to  slough.  This 
tendency  is  least  observed  in  the  integuments  about  joints, 
where  the  vascular  supply  of  the  skin  is  derived  from  many 
channels ;  elsewhere  an  extensive  skin-flap  is  very  liable  to 
perish  for  lack  of  blood  The  skin-flap  is  easily  adjusted  and 
faUs  readily  into  place.  It  aflbrds,  on  the  other  hand,  but  a 
shght  covering  to  the  bone,  and  a  scanty  protection  to  the 
stump.  The  slcin,  however,  in  some  regions  is  accustomed 
to  withstand  pressure,  and  affords  an  excellent  covering  for 
the  stump.  Such  regions  are  illustrated  by  the  heel,  the 
front  of  the  knee,  and  the  back  of  the  elbow. 


METHODS    OF   AMPUTATING.  295 

It  is  urged  that  the  skin  covering  a  stump  does  not  waste 
to  an  appreciable  extent,  but  that  the  muscular  tissue  con- 
tained therein  undergoes  complete  atrophy  in  the  course  of 
time,  so  that  the  stump  fashioned  out  of  muscle-flaps  is 
reduced  at  some  period  to  the  condition  of  a  stump  with  a 
covering  composed  of  integument  only. 

While  it  is  true  that  the  actual  muscle  fibres  in  the  stump 
become  more  or  less  completely  atrophied,  there  remains 
behind  a  solid  pad  of  fibrous  tissue  in  which  the  sheaths  and 
fibrous  connections  of  the  divided  muscles  form  the  most  im- 
portant elements,  and  in  which  the  bone  is  buried. 

In  general  terms  therefore  it  may  be  said  that  the  best 
flaps  are  those  which  contain  muscular  tissue,  provided  always 
that  the  skin  covering  the  stumps  be  longer  than  the  divided 
muscles  which  it  contains.  The  amount  of  muscle  contained 
in  the  flap  must  depend  upon  the  situation  of  the  amputation, 
the  contractility  of  the  divided  muscles,  and  the  covering 
required  for  the  bone.  If  it  be  considered  desirable  that  a  flap 
should  contain  a  main  artery,  this  cannot  be  effected  unless  a 
muscular  flap  be  dissected  up. 

B.  Varieties  of  Flaps. — 1.  Single  Flap. — This  was  the 
original  Tiiethod  of  Loiudham.  A  single  flap  involves  a  con- 
siderable sacriflce  of  tissues  upon  one  aspect  of  the  limb.  It  is 
well  adapted,  however,  for  certain  instances  of  amputation  for 
limited  injury  or  disease. 

As  an  example  of  amputation  by  single  flap  formed  of  skin 
only  may  be  cited  the  disarticulation  at  the  knee-joint 
by  a  long  anterior  flap  (page  497),  and  as  examples  of  single 
muscular  flaps  Farabeuf 's  amj)utation  of  the  leg  at  the  place  of 
election  (page  479),  the  disarticulation  at  the  wrist  by  a  single 
external  flap  (page  352),  and  the  amputation  at  the  shoulder- 
joint  by  a  deltoid  flap  (page  391)  may  be  quoted. 

2.  Double  Flaps. — Ravaton  (1739)  made  a  circular  incision 
do'svn  to  the  bone,  and  then  added  a  longitudinal  cut  on 
either  side  of  the  limb,  so  as  to  form  two  square  flaps,  each 
equal  to  half  the  thickness  of  the  limb.  These  so-called  flaps 
consisted  of  unwieldy  square  blocks  of  muscle,  and  the 
resulting  stump  was  uncouth.  "  Mavaton's  method"  although 
the  prototype  of  the  operation  by  double  flaps,  cut  from  with- 
out inwards,  soon  ceased  to  be  practised. 


296  OPERATIVE    SURGERY. 

Verinales  method  laid  the  foundation  of  the  double-flap 
operation  of  modern  times.  Yermale  cut  both  flaps — when- 
ever possible — by  transfixion,  and  was  thus  enabled  to  fashion 
them  more  neatly  and  to  reduce  the  amount  of  muscular 
tissue  left  in  the  stump. 

Sedillofs  Tnethod  differed  from  Vermale's  in  that  the 
operator,  instead  of  keeping  his  knife  close  to  the  bone  in 
transfixing,  passed  the  knife  through  the  muscles  nearer  to  the 
surface  of  the  limb.  Each  flap  so  fashioned  contained  but  a 
small  portion  of  muscular  tissue.  The  remaining  muscles, 
together  with  the  great  vessels,  were  then  divided  by  a  circular 
incision  and  the  amputation  completed  as  in  the  ordinary 
circular  operation. 

This  procedure  is  nearly  identical  with  the  modified 
circular  method. 

Langenbeck's  method  consists  in  cutting  double  flaps  from 
without  inwards,  thus  elaborating  Ravaton's  operation.  This 
plan  enables  the  surgeon  to  fashion  the  flaps  with  great 
precision,  and  it  is  the  method  of  flap-cutting  most  usually 
adopted  at  the  present  day. 

A  combination  of  the  two  last-named  methods  soon  became 
common  in  amputation  through  the  leg.  The  anterior  flap 
was  cut  from  without  inwards  and  the  posterior  by  trans- 
fixion. 

Some  surgeons  (Dupuytren,  Larrey)  made  the  skin 
incisions  by  cutting  from  without  inwards,  and  then  com- 
pleted the  flaps  by  transfixion.  (See,  as  an  example,  amputa- 
tion of  the  arm  by  antero-posterior  flaps.) 

Among  the  more  speciaHsed  methods  of  cutting  flaps  may 
be  named  Teale's  method,  fully  described  in  the  account  of 
amputation  of  the  leg ;  and  Lister's  method,  which  is  detailed 
in  the  description  of  amputation  through  the  condyles  of  the 
femur. 

Double  flaps  may  be  lateral  or  antero-posterior.  They  may 
be  equal  in  size  or  unec[ual.  In  order  to  meet  the  cylindrical 
form  of  the  limb,  the  flaps  will  be  better  fitting  if  made  of 
U  shape  than  if  cut  square.  Double  flaps  are  generally  so 
made  as  to  be  equal  in  width. 

Examples  of  every  form  of  double  flap  occur  in  the  descrip- 
tion of  individual  operations  which  follows. 


METHODS    OF   AMPUTATING.  297 

c.  Modes  of  Cutting  Flaps. — The  methods  of  fashioning 
flaps  have  been  ah-eady  in  general  terms  alluded  to.  Con- 
sidered more  in  detail,  and  from  the  point  of  view  of  the 
manipulation  of  the  knife,  three  methods  of  cutting  flaps  may 
be  specitied : — 

1.  By  transfixion. 

2.  By  cutting  from  without  inwards  (par  entaille). 

3.  By  dissection  (par  desossement). 

In  cutting  by  transfixion  a  long  loiife,  equal  in  length 
to  one  diameter  and  a  half  of  the  limb,  is  employed.  The 
following  is  the  description  of  an  amputation  of  the  arm 
by  double  flaps  cut  by  transfixion  as  given  in  Heath's 
"  Operative  Surgery  "  : — "  The  hmb  being  held  away  from  the 
trunk  by  an  assistant,  the  operator  grasps  the  biceps,  with 
the  brachial  vessels  and  nerves,  and  entering  the  point  of 
the  knife  upwards  close  below  his  thumb,  passes  it  in  fi'ont 
of  the  humerus,  depressing  the  point  as  it  appears  on  the 
opposite  side  close  to  the  operator's  fingers.  With  a  steady 
sawing  movement,  a  flap  from  two  to  three  inches  long  is  cut, 
with  the  skin  left  longer  than  the  muscles.  Drawing  up  the 
flap  with  his  fingers,  the  operator  passes  the  knife  behind  the 
bone,  and  cuts  a  shghtly  larger  flap  behind,  bringing  out  the 
knife  abruptly  at  the  last.  Both  flaps  being  gently  retracted, 
the  knife  is  swept  round  the  bone,  which  is  then  sawn  steadily 
through,  the  thumb  and  fingers  of  the  left  hand  protecting  the 
soft  tissues." 

By  another  method  the  skin  incisions  may  be  made  by 
cutting  from  without  inwards  and  the  exposed  muscles  be 
then  divided  by  transfixion.  This  is  illustrated  by  the  ampu- 
tation of  the  arm  by  antero-posterior  flaps  (page  376). 

2.  In  cutting  a  flap  from  without  inwards,  the  outline  of 
the  future  flap  is  at  first  marked  out  by  an  incision  which 
concerns  only  the  skin  and  the  subcutaneous  tissues.  When 
the  skin  has  retracted,  the  muscles  are  divided  down  to  the 
bone  by  cutting  from  without  inwards. 

For  this  purpose  a  small  but  strong  knife  is  employed 
(Fig.  74),  and  the  edge  is  directed  obliquely  towards  the  bone, 
so  that  the  muscular  tissue  shall  be  cut  unevenly,  the  thinnest 
section  being  along  the  margin  of  the  flap,  the  thickest  at  its 
base. 


298  OPERATIVE    SURGERY. 

An  illustration  of  this  method  is  afforded  by  the  dis- 
articulation at  the  shoulder-joint  by  an  external  or  deltoid 
flap  (page  891). 

As  the  skin  is  allowed  to  retract  before  any  muscular  tissue 
is  cut,  the  integument  of  the  stump  must  of  necessity  be  longer 
than  the  contained  muscle. 

3.  In  separating  a  flap  by  dissection,  the  flap  is  at  first 
marked  out  by  a  skin  incision,  and  when  the  integuments  have 
sufiiciently  and  evenly  retracted  the  muscular  part  of  the  flap 
is  cut  with  great  care.  The  knife  is  passed  obliquely  through 
the  muscle  to  the  bone,  and  the  soft  parts  forming  the  apex  of 
the  flap  having  been  completely  divided,  the  rest  of  the  deeper 
tissues  of  the  flap  are  very  carefully  dissected  up  or  peeled  off 
from  the  bone. 

This  method  is  well  illustrated  by  the  amputation  of  the 
leg  at  the  place  of  election  by  a  single  external  flap. 

Here  the  flap,  from  its  base  to  its  apex,  contains  the 
anterior  tibial  artery,  and  the  mass  of  muscular  tissue  forming 
the  flap  is  peeled  from  the  tibia,  fibula,  and  interosseous 
membrane. 


299 


CHAPTER   VI. 

The  Selection  of  Methods  for  Amputating. 

In  selecting  a  specific  method  for  performing  an  amputa- 
tion respect  must  be  had  for  the  adage  that  "  the  coat  must 
be  cut  according  to  the  cloth."  Each  case  must  be  taken  upon 
its  merits,  and  regard  be  observed  for  the  structural  condition 
of  the  limb, 

A  method  well  adapted  for  a  stout  or  muscular  subject  in 
the  prime  of  life  may  not  be  suited  for  an  identical  operation 
when  performed  upon  a  much-wasted,  aged,  or  cachectic  in- 
dividual. In  performing  a  circular  amputation,  retraction  of 
the  sldn  may  be  rendered  difficult  by  reason  of  existing  cedema 
or  induration ;  or  the  integuments  may  have  been  rendered 
rigid  and  adherent  by  a  long-abiding  inflammation. 

The  muscles  also  may  not  contract  when  divided ;  they 
may  be  found  atrophied,  or  converted  into  fatty  or  fibrous 
tissue,  or  be  matted  together  by  inflammation,  or  be  paralysed 
from  disease  or  disuse. 

Flaps  hkewise  may  have  to  be  modified  to  avoid  diseased 
districts,  ulcers,  sinuses,  and  the  hke.  The  skin  and  muscles 
may  not  contract  on  division.  The  muscular  tissue  may 
be  so  atrophied  that  enough  scarce^  remains  to  form  the 
substance  of  a  substantial  flap. 

The  main  artery  of  the  hmb,  or  the  vessel  which  is  to 
form  the  prmcipal  artery  of  the  flap,  may  be  found  to  be 
occluded  and  the  circulation  to  be  diverted  into  many  collateral 
channels.  In  such  case  the  main  vessels  may  scarcely  require 
a  ligature,  while  haemorrhage  Avill  occur  from  a  number  of 
divided  arteries  anatomically  insignificant. 

It  is  recommended  in  some  amputations — notably  the  am- 
putation of  the  leg  by  a  large  posterior  flap — that  the  main 
nerve  (in  the  case  cited,  the  posterior  tibial)  should  be 
removed   by   dissection.     On  performing  the    operation    the 


300  OPERATIVE   SURGERY. 

nerve  may  be  found  to  be  buried  among  a  mass  of  inflam- 
matory material,  and  its  excision  to  be  so  difficult  as  to  render 
the  necessar}^  prolongation  of  tlie  operation  unjustitiable. 

In  the  comments  upon  the  various  methods  of  amputating 
described,  the  comparative  value  of  each  procedure  is  dis- 
cussed. 

It  is  difficult  to  claim  an  unreserved  superiority  for  any 
one  method.  While  m  one  situation  the  circular  amputation 
is  undoubtedly  the  best,  in  another  it  is  with  equal  certainty 
the  least  efficient  method  of  dealing  with  the  part.  The 
same  may  be  said  of  any  one  method  of  performing  amputa- 
tion by  the  cutting  of  flaps. 

The  main  points  to  be  considered  in  the  selection  of  a 
method  are  the  following  : — 

1.  The  least  sacriflce  of  the  healthy  tissues  of  the  limb, 

2.  The  providing  of  a  good  and  permanent  covering  for  the 
bone. 

3.  The  obtaining  of  as  small  a  wound  area  as  is  con- 
sistent with  the  proper  performance  of  the  amputation. 

4.  The  securing  of  a  good  blood  supply  for  the  flaps  or 
tissues  which  wiU  form  the  stumj). 

5.  The  production  of  a  well-adjusted  cicatrix,  and  one 
so  placed  as  to  assist  the  healing  process,  secure  efficient 
drainage,  and  be  removed  from  pressure  when  the  stump  has 
healed. 

6.  The  ease  with  which  the  bone  can  be  exposed  at  the 
saw-line,  and  the  general  simplicity  of  the  method. 

7.  The  cutting  of  the  main  vessels  trans versel}^ 

8.  The  rapidity  Avith  which  the  amputation  can  be  per- 
formed. 

The  last  point,  which  was  at  one  time  almost  the  most 
important,  is  now  one  of  the  least  to  be  considered.  Before 
the  days  of  anesthetics,  speed  was  the  primary  good  quality 
in  any  amputation  method,  and  it  was  customary  to  estimate 
the  value  of  a  procedure,  first  of  all,  by  the  number  of  seconds 
or  minutes  involved  in  the  removal  of  the  limb. 

Chloroform  and  ether  have  entirely  changed  this  ground 
for  criticism — wider  issues  are  now  concerned ;  the  minimum 
sacrifice  of  parts,  and  the  well-being  and  utility  of  the  stump, 
are  now  primary  considerations,  and  amputations  are  effected 


METHODS    OF   AMPUTATING.  301 

with  some  of  the  care  and  precision  -which  characterise  the 
plastic  operations  of  surgery. 

The  ellipticcd  and  oval  methods  require  no  further  con- 
sideration. Tliey  are  founded  upon  the  circular  operation,  are 
of  hmited  appHcation,  and  are  admirably  adapted  to  the  parts 
at  which  they  are  practised. 

In  comparing  the  circular  and  flap  methods  one  con- 
spicuous consideration  is  the  resulting  wound  area. 

The  investigations  of  Farabeuf  show  that  in  a  limb  with  a 
diameter  of  10  cm.  the  wound  area  {la  surface  saignante)  of 
the  stump  will  be  110  square  cm.  after  both  the  ordinary 
circular  amputation  and  the  amputation  by  two  equal  rounded 
flaps,  and  will  be  125  square  cm.  after  an  amputation  by  a 
single  rounded  flap. 

The  circtdar  operation  provides,  then,  a  small  wound  sur- 
face. It  involves  the  least  sacrifice  of  the  healthy  Hmb ;  it  is 
easily  performed ;  the  blood-vessels  and  muscles  are  cut 
cleanly  and  transversely,  and  the  soft  parts  covering  the  bone 
are  well  supplied  with  blood. 

On  the  other  hand,  the  operation  cannot  be  well  performed 
without  an  assistant;  the  exposure  of  the  bone  at  the  saw- 
line  is  not  always  effected  with  ease  and  without  undue 
disturbance  of  the  soft  parts,  and  the  edges  of  the  wound  do 
not  fall  easily  together.  Moreover,  in  muscular  limbs  the 
after-retraction  of  the  divided  muscles  is  very  apt  to  lead  to 
a  conical  stump.  Indeed,  one  of  the  most  common  examples 
of  such  a  stump  is  provided  by  carelessly  performed  circular 
amputations  of  the  thigh  in  muscular  subjects. 

In  wasted  individuals,  and  under  conditions  where  mus- 
cular retraction  is  inconsiderable,  this  objection  does  not 
hold. 

The  circular  method  is  not  adapted  for  cases  of  injury  or 
disease  when  the  parts  near  the  site  of  the  amputation  are 
unequally  involved 

The  flap  method,  as  represented  by  flaps  cut  either  from 
without  inwards  or  by  dissection  {see  page  297),  is  capable  of 
adapting  itself  to  many  conditions  and  to  an}^  part. 

It  is  particularly  valuable  in  instances  of  unequal  de- 
struction of  the  parts  of  a  limb. 

The  area  of  the  wound  surface  may  be  as  already  pointed 


302  OPERATIVE    SURGERY. 

out,  larger,  and,  other  things  being  equal,  it  may  be  allowed 
that  the  flap  operation  involves  a  greater  sacrifice  of  tissue  than 
does  the  circular.  The  blood-vessels  may  be  cut  obliquely, 
and  may  even  be  slit  up.  The  muscles  are  divided  obliquely. 
In  long  flaps  there  is  a  danger  of  their  tissues  perishing  from 
an  insufficient  blood  supply.  The  operation  is  in  some 
forms  difficult,  but  can  usually  be  performed  with  less 
skilled  assistance. 

On  the  other  hand,  the  bone  at  the  saw-line  can  be 
readily  exposed ;  the  flaps  fall  easily  together  ;  the  site  of  the 
future  scar  can  be  modified  as  required  ;  the  coverings  of  the 
stump  can  be  fashioned  so  as  to  meet  the  varying  conditions 
of  the  limb,  and  the  development  of  a  conical  stump  can  be 
more  surely  avoided  after  a  flap  amputation  than  after  the 
circular  operation. 

As  to  the  cutting  of  the  flaps  themselves,  the  methods  by 
cutting  from  without  in  and  by  dissection  are,  beyond  doubt, 
the  best.  Flaps  so  fashioned  can  be  formed  with  great  pre- 
cision. The  proportion  of  contained  tissue  can  be  determined 
with  accuracy,  and  the  exact  relations  between  the  amount  of 
skin  and  of  muscle  covering  the  bone  can  be  regulated  with 
ease.  Main  vessels  need  never  be  slit  up,  and,  indeed,  under 
many  conditions  these  structures  may  be  exposed  and  secured 
before  division.  By  these  methods  also  the  smallest  possible 
section  of  muscles  can  be  accomplished. 

Some  part  of  a  flap  may  be  conveniently  cut  by  transfixion, 
as  in  Hey's  amputation  through  the  middle  of  the  leg,  and 
the  disarticulation  at  the  elbow-joint  by  the  elliptical  method. 
The  part  so  divided  must  belong  to  the  muscular  portion  of 
the  flap. 

The  cutting  of  a  large  flap  by  transfixion  alone,  in  such  a 
way  that  the  knife  divides  both  muscles  and  integument  at 
one  sweep,  is  to  be  strongly  condemned. 

The  method  has  one  recommendation  only — it  is  rapid. 

If  the  rapidity  with  which  a  limb  can  bo  removed  should 
prove  in  any  case  to  be  a  matter  of  the  first  importance, 
then  the  amputation  by  flaps  cut  by  transfixion  may  be 
entertained.  Such  operations  are  described  in  connection 
with  aui})Utations  of  the  thigh,  and  disarticulations  at  the 
hip-joint. 


METHODS    OF   AMPUTATING.  303 

The  following  objections  are  to  be  urged  against  tbe  trans- 
fixion method : — The  surgeon  has  little  control  over  the  large 
knife  he  must  employ.  The  flaps  cannot  be  cut  with  pre- 
cision, nor  can  their  thickness  be  very  accurately  gauged. 
The  skin  is  divided  together  with  the  superficial  layer  of 
muscular  tissue.  The  muscles  themselves  are  cut  obliquely. 
The  main  vessels  may  be  transfixed,  or  may  be  cut  unduly 
short,  or  may  be  sliced  up.  Much  tissue  at  the  bases  of 
the  flaps  escapes  division,  and  requires  to  be  cut  before  the 
bone  can  be  cleared  for  sawing. 

The  method  belongs  to  the  past,  to  a  period  of  "  brilliant " 
surgery,  when  the  shrieking  and  terror-stricken  patient  was 
held  in  the  amputation-chair  by  many  lusty  assistants, 
and  the  operator's  pupil  stood  by  with  a  fob-watch  in  his 
hand. 


301 


CHAPTER    VII. 

General  Points  in  the  Performance  of  Amputations. 

A.  The  Handling  of  the  Knife. — It  is  needless  to  point 
out  that  an  amputating-knife  is  a  powerful  instrument,  with 
the  edge  of  a  razor,  and  that  it  must  be  wielded  with  in- 
finite care  and  precision.  It  is  a  dangerous  instrument  in 
the  hands  of  the  surgeon  who  believes  that  limbs  should 
be  "  slashed  off,"  and  that  an  operator's  ability  is  to  be 
estimated  by  the  number  of  seconds  involved  in  the  procedure. 
Flaps  should  be  planned  with  the  minutest  care,  and  it  is 
better  that  the  lines  of  the  intended  incisions  should  be 
marked  upon  the  limb  in  crayon  before  the  operation  than 
that  the  surgeon  should  trust  to  his  eye  and  the  hope  that 
"  the  flaps  will  come  together."  Each  incision  should  be  made 
dehberately,  and  should  be  final. 

The  "  trimming  "  of  flaps  is  usually  an  evidence  of  incom- 
petence. 

The  greatest  possible  care  should  be  taken  of  the  principal 
arteries,  lest  the  stump  be  left  anaemic. 

In  the  hasty  and  careless  cutting  of  flaps,  especially  by 
transfixion,  it  is  very  easy  for  the  main  artery  of  the  part 
to  be  slit  up  or  divided  at  too  high  a  level. 

Nerves  and  tendons  should  be  cut  short,  arteries  long. 

In  dividing  tendons  a  sharp,  vigorous  cut  is  needed,  and 
the  tendon  should  be  put  upon  the  stretch  at  the  time  the 
knife  is  applied. 

If  after  the  limb  be  removed  any  tendons  are  left  "  long," 
i.e.,  hanging  from  the  surface  of  the  stump  (as  may  occur  after 
Syme's  amputation),  they  should  be  seized  with  bull-dog  artery- 
forceps,  put  on  the  stretch,  and  divided  by  strong  scissors. 
Loose  tendons  are  not  readily  severed  by  a  knife. 

B.  The  Handling  of  the  Saw. — Care  should  be  taken,  in 


PERIOSTEAL    FLAPS    IN   AMPUTATION.  305 

the  first  place,  that  the  bone  is  not  bared  too  high  above  the 
site  of  the  future  saw-Hne. 

If  a  i^eriosteal  flap  is  to  be  made,  this  membrane  itself 
should  not  be  actually  exposed.  A  flap  large  enough  to  cover 
the  divided  end  of  a  bone,  and  composed  solely  of  periosteum, 
is  probably  useless  and  destined  to  slough. 

The  flap  should  contain  not  only  the  periosteum,  but  the. 
deepest  muscular  layers  about  the  bone.  These  two  tissues 
should  be  separated  from  the  bone  together.  It  is  through 
the  muscular  tissues  that  the  blood-vessels  reach  the  peri- 
osteum. 

A  circular  incision  having  been  made  down  to  the  bone,  at 
a  proper  distance  below  the  intended  saw-line,  two  vertical 
incisions — one  on  either  side  of  the  bone — are  then  made  from 
the  site  of  the  saw-line,  to  join  the  circular  cut.  Two  equal 
flaps  of  musculo-periosteal  tissue  are  then  dissected  up  with  a 
periosteal  elevator,  are  carefully  protected  while  the  bone  is 
being  sawn,  and  are  allowed  to  fall  over  the  divided  end  of 
the  bone  when  the  flaps  are  adjusted  If  thought  desirable, 
one  or  two  points  of  suture  may  be  introduced  to  secure  the 
little  flaps  in  place.  In  young  subjects  the  periosteum 
separates  readily,  and  the  same  may  be  said  in  some  instances 
of  operation  for  disease.  In  these  cases  the  vertical  incisions 
may  be  dispensed  with,  as  they  maj''  also  be  when  the  ampu- 
tation concerns  small  bones.  In  dealing  with  the  tibia  and 
femur,  however,  forcible  attempts  to  separate  a  periosteal 
sheath  without  the  aid  aftbrded  by  lateral  incisions  not 
improbably  inflict  a  permanent  damage  upon  the  little  flap. 
In  healthy  adults  the  membrane  is  often  difficult  to  detach. 

The  value  of  the  periosteal  flap  has  not  yet  been  clearly 
demonstrated  in  all  cases,  and  it  may  be  a  question  whether  it 
is  always  worth  the  time  involved  in  its  production.  Its  most 
elaborate  and  apparently  most  beneficial  application  has  been 
associated  Avith  amputations  at  the  hip -joint. 

In  using  the  saiv,  the  first  care  is  to  make  a  groove  on  the 
bone  in  which  the  saw  shall  run  smoothly,  without  risk  of 
slipping  and  damaging  the  soft  parts  around. 

It  is  well  to  fix  the  thumb-nail  of  the  left  hand  into  the 
bone  just  above  the  saw-lme,  while  the  blade  of  the  saw  is 
rested  and  steadied  aofainst  the  knuckle  of  the  thumb. 


306  OPEBATIVE    SURGERY. 

The  saw  should  he  held  quite  lightly  at  first,  and  should  be 
drawn  from  heel  to  point  in  making  the  groove. 

The  bone  can  then  be  divided  by  long,  firm,  slow  cuts. 

The  whole  length  of  the  saw-blade  should  be  used.  The 
hand  should  be  light. 

Rapid  sawing  is  bad,  as  is  also  the  use  of  large  and  coarse- 
toothed  saws.  A  not  inconsiderable  amount  of  heat  is  de- 
veloped during  the  sawing  process,  and  it  is  possible  that  the 
superficial  necrosis  of  the  entire  sa"\vn  end  of  the  bone,  some- 
times met  with  after  amputation,  may  be  due  to  the  rough  and 
violent  use  of  the  saw. 

As  the  division  of  the  bone  approaches  completion  the 
strokes  made  with  the  saw  should  be  short  and  again  very 
light. 

When  two  bones  require  division,  a  good  groove  should  first 
be  made  in  the  larger  one,  and  when  the  saw  has  obtained  a 
sure  hold  its  edge  can  be  dropped  upon  the  smaller  bone. 

The  division  of  the  smaller  or  more  movable  bone  should  be 
completed  first. 

During  the  sawing  process,  MacCormac  advises  that  a  stream 
of  carbolised  water  should  be  allowed  to  pour  over  the  bone. 

Special  methods  for  dividing  the  tibia  and  fibula  are 
described  in  the  account  of  Farabeufs  amputation  of  the  leg 
at  the  "  place  of  election." 

Every  care  should  be  taken  that  the  soft  parts  are  well 
protected  during  the  process  of  sawing. 

The  assistant  who  holds  the  limb  should  hold  it  horizontally 
and  at  right  angles  to  the  saw-blade.  If  the  limb  be  held  too 
high  or  too  low,  or  be  not  properly  supported  close  below  the 
site  of  the  amputation,  the  saw  is  apt  to  be  locked,  or  the 
bone  to  break  before  its  division  is  completed. 

The  assistant  should  draw  the  limb  away  from  the  trunk, 
while  at  the  same  time  he  supports  it  efficiently. 

Any  splinters  of  bone  should  be  removed  with  bone-forceps. 

The  division  of  small  bones,  such  as  those  of  the  fingers 
or  metacarpus,  by  bone-forceps  is  to  be  condemned.  By 
such  division  the  bone  is  crushed  and  splintered,  and  need- 
lessly damaged.  This  is  especially  the  case  with  the  bones  of 
well-developed  adults  and  of  aged  persons. 

The  division  of  these  slender,  long  bones  is  best  effected  by 


HEMORRHAGE    IN   AMPUTATION.  307 

means  of  a  very  fine  saw,  and  for  the  purpose  the  smallest 
form  of  bow-saw  answers  admirably. 

The  not  infrequent  separation  of  spicules  of  necrosed  bone 
after  amputations  of  the  fingers  and  toes  is  probably  often  due 
to  the  splintering  and  crushing  of  the  bones  produced  by  the 
bone-forceps.  The  forceps  effect  the  division  of  the  shaft 
speedily,  but  at  a  great  sacrifice,  and  their  use  is  opposed  to 
one  of  the  first  principles  of  surgery. 

c.  The  Arrest  of  Bleeding-. — In  arresting  bleeding  after 
amputations  there  is  little  to  be  noted  in  addition  to  what  has 
been  written  in  a  previous  chapter  (page  57). 

After  the  bone  has  been  sawn,  the  stump  should  be  sup- 
ported by  an  assistant,  who  can,  at  the  same  time,  hold  up  any 
flap  and  generally  do  his  best  to  expose  the  whole  surface  of 
the  Avound. 

The  main  vessels  may  have  been  secured  before  or  during 
the  fashioning  of  the  flaps.  In  the  majority  of  cases,  how- 
ever, this  is  not  done.  The  surgeon  and  his  assistants,  the 
moment  the  avouucI  surface  is  well  exposed  after  the  amputa- 
tion, should  seize  all  the  visible  divided  arteries  with  pressure- 
forceps.  The  operator  should  secure  the  principal  vessels, 
while  one  or  more  assistants  grasp  any  minor  trunks  which 
may  be  noticed. 

Dining  this  preliminary  securing  of  the  severed  arteries, 
the  pressure  upon  the  main  vessel  should  still  be  maintained 
by  the  assistant  who  is  responsible  for  the  control  of  haemor- 
rhage during  the  amputation. 

While  the  hgatures  are  being  applied  the  stump  should 
be  supported  in  an  elevated  position.  In  the  case  of  the 
upper  limb  an  assistant  can  readily  effect  this.  After  an 
amputation  of  the  lower  limb  the  stump  should  be  supported 
upon  a  block  similar  to  those  used  in  dissecting-rooms  to 
receive  the  head  of  the  subject.  The  block  is  padded  and 
covered  neatly  with  macintosh,  and,  when  in  use,  a  towel 
soaked  in  some  antiseptic  solution  may  be  placed  over  it.  By 
this  means  the  whole  area  of  the  Avound  is  well  exposed  to 
view,  the  stump  is  kept  perfectly  stead}^  and  is  maintained  at  a 
convenient  elevation. 

Pressure  upon  the  main  artery  being  relaxed,  any  smaller 
bleeding  points  are  secured  with  clamp-forceps. 


308  OPERATIVE    SURGERY. 

The  cut  vessels  are  finally  closed  in  the  manner  already- 
described,  some  by  pressure  merely,  some  by  torsion,  the  re- 
mainder by  ligature  (page  58). 

It  is  well  that  a  ligature  should  be  placed  upon  the  main 
vein,  or  upon  any  other  vein  from  which  blood  continues  to 
ooze. 

Persistent  bleeding  from  the  sa-^vn  surface  of  the  bone  may 
usually  be  checked  by  gentle  pressure  maintained  for  some 
time  with  a  piece  of  sponge.  If  it  still  continue,  a  piece  of 
ice  may  be  held  against  the  oozing  surface. 

Bleeding  from  a  distinct  artery  in  the  bone  seldom  calls 
for  further  means  than  these.  Should  it,  however,  be  main- 
tained, an  attempt  should  be  made  to  separate  the  coats  ot 
the  vessel  from  the  wall  of  the  bony  canal  by  means  of  a  tine 
needle,  and  then  to  force  them,  when  separated,  into  the  canal 
so  as  to  form  a  kind  of  natural  plug. 

Failing  this,  the  orifice  may  be  blocked  by  a  piece  of  catgut, 
or  by  a  small  pellet  of  wax.  I  have  never  met  with  a  case 
which  called  for  the  use  of  "  the  sharpened  end  of  a  wooden 
match  "  as  a  plug. 

This  plug,  which  so  many  authors  allude  to,  is  probably 
intended  to  be  no  more  than  a  picturesque  example  of  fertility 
of  resource. 

D.  The  Closure  of  the  Wound. — The  cleansing  of  the  wound 
surface  and  the  application  of  the  sutures  are  conducted  in  the 
manner  already  described  (page  5S). 

There  should  be  no  tension  upon  the  wound,  no  dragging 
of  the  flaps  together,  no  attempt  to  cover  the  bone  by  traction 
upon  the  soft  parts.     The  edges  should  fall  together. 

To  unite  the  wound  a  long,  straight  needle  is  employed, 
and  the  best  suture  material  is  silkworm  gut. 

If  the  sutures  are  applied  at  a  proper  distance  apart,  and  if 
firm  and  even  pressure  is  employed,  so  as  to  approximate  the 
wound  surfaces  and  obliterate  any  cavities  or  pockets  between 
the  flaps,  no  drainage-tubes  may  be  required.  If  a  sinus  has 
been  exposed  during  the  amputation,  and  has  been  scraped 
out,  a  tube  may  be  allowed  to  occupy  its  cavity  for  a  day  or 
so  if  thought  necessary.  If  the  knife  has  passed  through 
ocdematous  tissues,  nmch  oozing  must  of  necessity  occur  after 
the  operation,  and  to  allow  this  to  have  free  exit  a  tube  may 


TREATMENT    OF    THE    AMPUTATION    WOUND.       3u9 


be  employed  for  24  or  48  hours.  The  escape  of  the  fluid, 
however,  can  usually  be  as  well  provided  for  by  leaving  suit- 
able intervals  between  the  sutures  at  the  most  dependent  part 
of  the  wound. 

The   general   question  of  the  use  of  drainage-tubes  has 
already  been  considered  (page  64). 

The  stump  must  be  properly  supported  after  the  operation, 
and  care  taken  that  all  traction  is,  as  far  as  possible,  taken  off 
the   flaps.      In   a  large  proportion  of  the  cases  of  amputa- 
tion the  support 
of    a    splint    is 
required.       The 
splint  serves  to 
support  the  flaps, 
to  maintain  the 
limb  at  rest,  and 
to  favour  the  ap- 
plication of  such 
pressure  as  is  re- 
quired (Fig.  76). 

More  specific  details  as  to  the  after-treatment  of  amputa- 
tion wounds  are  given  in  the  chapters  which  follow. 


Fig.  76. 


-SUPPORTING  SPLINT  ADJUSTED  TO  THE  LEG  AFTEB 
CHOPART'a  AMPUTATION. 


810 


CHAPTER    VIII. 

The  Future  of  the  Stump. 

The  success  of  an  amputation  depends  upon  a  groat  many- 
factors.  Tlie  more  general  of  these  have  been  abeady  con- 
sidered in  dealing  with  the  circumstances  which  influence  the 
future  of  all  operations  (page  1). 

The  local  conditions  are  also  very  numerous. 

1.  The  State  of  the  Limb. — In  cases  of  injury,  for  example, 
the  amputation  may  not  be  performed  high  enough  up,  the 
flaps  may  have  been  fashioned  from  damaged  tissues,  and  the 
structures  of  the  stump  will  perish  in  due  course  from  slough- 
ing or  suppuration. 

In  removing  a  hmb  for  any  spreading  disease,  it  is  possible 
that  the  hmits  of  the  affected  area  have  not  been  clearly 
recognised,  and  that  the  stump  becomes  in  turn  the  seat  of 
the  malady  for  which  the  amputation  was  performed. 

In  operations  for  gangrene  this  is  especially  to  be  noted. 

In  senile  gangrene,  or  in  gangrene  due  to  the  plugging  of  a 
main  artery,  the  involved  segment  of  the  limb  may  be  removed. 
As  the  knife  passes  through  the  apparently  healthy  tissues  it 
becomes  evident  that  they  also  are  on  the  verge  of  death. 
Little  blood  issues  fi'om  the  divided  vessels.  The  vascular 
supply  of  the  part  has  been  sufficient  to  support  a  jirecarious 
existence,  but  it  is  insufficient  to  meet  the  demands  made  by 
that  degree  of  inflammation  which  is  necessary  to  effect  heal- 
ing. Under  this  strain  the  local  powers  of  the  part  break 
down  and  the  flaps  themselves  pass  in  turn  into  the  gangrenous 
condition. 

In  amputations  performed  for  sloughing  conditions  due  to 
nerve  lesions,  the  same  sequel  of  events  may  be  noted.  The 
condition  that  led  to  the  sloughing  process  is  not  removed  by 
the  surgeon's  knife.  Its  influence  affects  the  segment  of  the 
limb  through  which  the  blade  has  passed. 


FUTURE    OF    THE    AMPUTATION   STUMP.  :311 

Tissues  that  could  have  Uved  if  left  undisturbed,  cannot 
display  the  vital  energy  demanded  in  a  healthy  flap.  The 
flaps,  or  jDortions  of  them,  slough,  or  fail  to  heal,  and  the 
disease  is  said  to  have  reappeared  or  recurred  in  the  stump. 

It  should  be  reme»ibered  that,  to  secure  the  healing-  of 
an  amputation  Avound,  a  robust  recuperative  power  is  required 
in  the  tissues  concerned.  This  power  is  easily  enfeebled. 
Thus  a  ready  healing  of  the  wound  cannot  be  expected  Avhen 
the  flaps  are  cut  from  tissues  Avhich  have  been  repeatedly 
inflamed,  or  Avhich  are  actually  the  seat  of  inflammation,  or 
which  have  remained  long  cedematous. 

Amputations  for  chronic  joint-disease  illustrate  this  Avell 
enough,  especially  if  the  flaps  are  cut  from  tissues  Avithin  the 
actual  area  of  the  disease. 

The  tissues  may,  hoAvever,  hai^e  become  enfeebled  from 
other  causes  than  those  attending  inflammation.  They  may 
have  wasted  from  long  disuse.  The  muscles  may  be  atrophied 
and  fatty,  the  nerves  converted  in  great  part  into  connective 
tissue,  and  the  arterial  channels  considerably  reduced  in  size 
and  capacity. 

Although  the  subject  in  such  case  may  be  young,  the 
tissues  in  the  affected  limb  are  in  a  condition  of  senile  decay. 

The  long  Avearmg  of  splints,  the  long  use  of  tight  bandages, 
the  long  maintaining  of  the  hmb  in  an  elevated  position,  are 
all  conditions  Avhich  serve  to  place  the  parts  in  an  unfavour- 
able state  for  a  successful  amputation. 

2.  The  Site  of  the  Amputation. — It  aa^lU  be  obvious  that 
much  depends  upon  the  exact  spot  selected  for  an  amputation 
and  the  state  of  the  tissues  from  Avdiich  the  coverings  of  the 
stump  are  made. 

There  are  few  more  difficult  problems  in  practical  surgery 
than  the  selection  of  the  best  site  for  an  amputation,  and  feAV 
upon  which  less  precise  adA'ice  can  be  given. 

If  the  operator  make  the  securmg  of  primary  healing  the 
main  factor  in  deciding  upon  the  amputation  site,  then  he  Avill 
over  and  over  again  sacrifice  more  of  the  patient's  limb  than 
AA'as  necessary  or  perhaps  profitable. 

If,  on  the  other  hand,  he  regard  the  minimum  amount  of 
tissue  to  be  sacrificed  by  cutting  as  the  first  element  in 
forming  his  decision,  then  he  Avill  meet  Avith  many  cases  Avhere 


312  OPERATIVE    SUBGEBY. 

tlie  llaps  slough  and  where  the  ultimate  destruction  of  the 
limb  is  greater  than  would  have  occurred  had  the  amputation 
been  performed  higher  up  in  the  first  instance. 

Few  positions  in  surgery  are  more  unsatisfactory  than  that 
involved  by  a  second  amputation  rendered  necessary  by  the 
sloughing  of  the  stump  of  the  first. 

When  the  second  stump  has  healed,  the  operator  must 
feel  that  the  patient  might  have  been  saved  the  former 
operation  and  the  tedious,  painful,  and  dangerous  period 
which  preceded  the  final  amputation. 

There  is  constantly  the  difficulty  of  deciding  between  the 
sacrifice  of  a  few  more  inches  of  a  hmb  to  ensure  ready  healing 
and  the  saving  of  those  inches  at  the  risk  of  retarded  healing, 
possible  sloughing  of  the  stump,  and  the  subsequent  removal 
of  the  limb  at  a  spot  above  the  higher  of  the  two  points 
originally  compared.  In  not  a  few  instances  it  may  be  con- 
sidered wiser  that  the  risks  of  slow  healing,  with  suppuration 
and  a  tedious  granulation  process,  should  be  encountered, 
rather  than  that  a  greater  segment  of  the  limb  should  be 
sacrificed.  In  many  examples  of  amputation  for  injury  in 
healthy  men  this  is  the  case.  Every  inch  of  the  limb  is  of 
value ;  the  healing  process  may  be  slow,  may  involve  much 
suppuration  and  a  slow  process  of  closure  by  granulation,  but 
the  patient  is  robust  and  well  able  to  withstand  the  strain 
demanded,  and  in  the  end  it  proves  that  a  portion  of  the  limb 
has  been  saved  at  not  too  great  a  sacrifice. 

In  other  examples — notably  in  operations  for  long-standing 
disease — ready  healing  of  the  stump  is  a  matter  of  primary 
importance.  The  saving  of  a  few  inches  of  the  limb  is  a 
matter  of  subordinate  value.  The  patient  is  not  in  a  condition  to 
meet  a  vigorous  suppurative  process,  and  it  may  be  evident  that 
his  life  will  be  sacrificed  before  the  healing  process  is  complete. 
•  The  question  is  complicated  by  many  side-issues. 

In  the  case  of  amputation  for  injury,  for  example,  where 
almost  any  danger  in  the  future  is  anticipated  to  avoid  the 
present  sacrifice  of  a  larger  segment  of  the  limb,  the  patient 
recovers  after  a  tedious  suppurative  process  with  a  stump  so 
shrunken  and  so  ill-covered  that  it  is  worse  than  useless,  and 
he  has  to  be  content  to  remain  a  cripple  or  entertain  a  second 
amputation.    In  the  case  of  amputation  for  disease  also,  it  has 


FUTURE    OF    THE   AMPUTATION   STUMP.  313 

to  be  remembered  that  the  higher  the  amputation  the  gi-eatcr 
is  the  amount  of  shock  and  of  immediate  risk  to  life,  and  the 
carrying  out  of  a  high  amputation  to  ensure  speedy  healing  in 
a  debilitated  subject  may  involve  an  amount  of  shock  which 
proves  fatal. 

As  already  said,  the  question  is  one  of  great  difficulty,  and 
can  hardly  be  discussed  apart  from  the  actual  case,  every 
detail  of  which  must  in  every  instance  be  most  carefully  and 
patiently  weighed. 

3.  The  Manner  of  the  Operation. — Much  of  the  success  of 
the  amputation  must  obviously  depend  upon  the  manner  in 
which  it  is  done.  Many  evils  may  fall  under  this  head.  The 
flaps  have  been  indifferently  cut.  They  slough,  or  form  so  poor 
a  covering  to  the  bone  that  the  edges  of  the  wound  have  to  be 
forcibly  adjusted  by  the  sutures.  The  muscles  have  been 
jagged,  and  large  portions  of  muscular  tissue  nearly  separated 
from  the  flap  surface,  and  necessarily  cut  ofi:*  from  any 
sufficient  blood  supply,  have  been  left  to  perish.  The  flaps 
have  been  roughly  handled,  have  been  dragged  upon,  and 
have  been  injured  in  uncouth  eflbrts  to  expose  the  bone. 
Arteries  have  been  slit  up,  or  the  main  vessel  of  the  flap  has 
been  wounded  near  the  base  of  the  flap. 

Tendons  are  hanging  loose  in  the  depths  of  the  wound, 
and  are  so  far  cut  off  from  their  normal  vascular  supply  that 
they  must  perish  by  sloughing.  Masses  of  tissue  have  been 
recklessly  clamped  in  grasping  bleeding  vessels  with  the 
pressure  forceps.  The  wound  surface  has  been  violently 
sponged,  or  the  sutures  have  been  applied  before  all  haemor- 
rhage has  been  checked. 

The  soft  parts  about  the  bone  have  been  lacerated  by  the 
saw,  the  periosteum  has  been  extensively  destro3^ed,  and  saw- 
dust from  the  bone  has  been  ground  into  the  mangled 
muscular  tissue.  The  bone  may  have  been  splintered  by 
forceps,  and  fragments  of  the  shaft  left  in  the  wound.  The 
assistant  who  has  held  the  gangrenous  hmb  during  the 
amputation  has — without  washing  his  hands — held  the  main 
flap  after  the  limb  has  been  removed.  To  these  possible  evils 
must  be  added  such  as  attend  defective  cleansing  of  the 
woimd,  imperfect  securing  of  the  vessels,  and  faults  in  the 
after-treatment 


3U 


CHAPTER  IX. 

The  Mortality  after  Amputation. 

I.  The  General  Mortality. — Since  the  introduction  of  im- 
proved methods  of  ]3ei'formuig  amputation  and  of  treating 
wounds,  the  general  mortality  after  the  operation  has  been 
very  considerably  reduced. 

The  more  voluminous  statistics  pubhshed  are  of  little 
value  at  the  present  day,  since  they  deal  with  data  afforded 
by  older  and  much  less  successful  forms  of  practice,  and  are 
largely  composed  of  the  returns  of  army  surgeons.  It  is  note- 
worthy also  that  the  results  shown  by  different  statistics  vary 
considerably. 

Schede  has  compiled  a  table  of  321  cases  (occurring  in 
civil  practice)  of  amputations  performed  antiseptically,  and 
attended  by  a  mortality  of  only  4*4  per  cent,  while  in  387 
cases  of  amputation  of  equal  importance  treated  during  the 
pre-antiseptic  period  the  mortality  was  2918  per  cent. 

One  of  the  largest  tables  of  statistics  is  that  prepared  by 
Ashhurst.  He  deals  with  6,448  cases  of  amputation,  the 
great  mass  of  which  belongs  to  the  period  before  anti- 
septics. The  mortality  is  given  at  32'9  per  cent.  The 
statistics  of  the  Newcastle-on-Tyne  Infirmary,  as  prepared  by 
Mr.  Page,  give  in  10  years  ending  December,  1888,  484  cases 
of  amputation,  with  a  general  mortality  of  7 '6  per  cent. 
(Lancet,  July  13th,  1889). 

The  statistics  of  St.  Thomas's  Hospital  for  the  ten  years 
1876 — 1885  give  a  mortality  of  12-8  per  cent,  for  amputations 
of  all  kinds  performed  during  that  period. 

MacCormac  considers  that  this  mortality  "  probably  re- 
presents a  fair  average  of  the  results  attained  in  the  London 
hospitals." 

The  statistics  of  400  cases  of  amputation  (occurring  at 
St.  George's  Hospital  l^ctwcen  October,  1874,  and  June,  1888), 


MORTALITY   AFTER    AMPUTATION.  315 

prepared  by  Mr.  Dent,  give  a  general  mortality  of  21  per  cent. 
{Med.-Chir.  Tixms.,  vol.  Ixxiii.). 

2.  Influence  of  Age  and  Sex. — Age  has  an  important 
infiiience  on  the  results  of  amputation.  In  the  very  young — 
those  under  the  age  of  five  years — it  is  not  well  borne,  the 
mortality  often  being  as  high  as  between  the  ages  of  thirty-live 
and  fifty.  The  mortality  is  lowest  between  the  ages  of  five  and 
fifteen.  After  fifteen  the  death-rate  begins  to  steadily  in- 
crease, although  between  the  whole  period  of  twenty  to  forty 
the  variation  is  not  very  great.  From  fifty  to  sixty-five  the 
mortahty  rapidly  increases. 

Ashhurst  gives  the  following  conclusions  from  his  ex- 
tensive collection  of  statistics: — (1)  In  persons  under  twenty 
3'ears  old  the  operation  is  a  comparatively  safe  one,  but 
in  patients  fi'om  twenty  to  forty  it  is  nearly  twice,  and  in 
those  over  forty  not  far  from  iliree  times,  as  apt  to  be  followed 
by  death  as  during  the  earlier  period.  (2)  In  persons  over 
thirty  years  of  age  amputation  is  almost  twice  as  fatal  as  in 
those  who  are  younger. 

Mr.  Dent's  statistics  give  the  following  results : — 

A(/e.  Mortality. 

Under  5  ...         ...         ...  12-.5  per  cent. 

o  to  10  3-3       „ 

10  to  20  16-1        „ 

20  to  40  141        „ 

40  to  60  32-8       „ 

Over  60  70  „ 

Statistics  show  that  the  mortality  of  amputation  is  a  little 
loAver  in  women  than  in  men.  It  must  be  remeiubered,  how- 
ever, that  the  cases  of  amputation  in  men  are  much  more 
numerous,  and  include  a  larger  proportion  of  oi^erations  for 
injury. 

3.  Influence  of  the  Cause  of  the  Amputation. — Amputa- 
tions performed  for  disease  are  much  less  fatal  to  life  than 
those  performed  for  injury.  The  older  statistics  give  out  of  a 
total  of  6,448  amputations  of  all  kinds  a  mortahty  of  39'8  per 
cent,  in  the  operations  for  injury,  and  a  mortality  of  26'8  per 
cent,  in  the  amputations  performed  for  disease  or  deformity. 

The  records  of  the  London  Hospital  for  the  last  four  years 
show   the   mortality  after  amputation  of  the  leg  or  foot  for 


316 


OPERATIVE    SURGERY. 


injury  to  have  been  12  per  cent,  and  for  disease  to  have  been 
4  per  cent. 

MacCormac's  statistics,  deaHng  with  678  cases  of  amputa- 
tion of  all  kinds  performed  during  recent  years,  show  the 
mortaUt}^  after  amputations  for  injury  to  be  about  18"5  and  for 
disease  to  be  about  10*5  per  cent. 

Mr.  Page's  statistics,  dealing  with  484  like  cases,  give  a 
mortality  in  cases  of  injury  of  12-3  per  cent.,  and  in  disease  of 
4-9  per  cent.  Mr.  Dent's  series  of  cases  show  a  mortality  of 
15 "2  per  cent,  in  amputations  for  disease,  and  of  36 "6  in  ampu- 
tations for  injury. 

Primary  amputations  for  mjury  are  less  fatal  than 
secondary  amputations  for  injury.  MacCormac  gives  the 
mortahty  of  the  former  as  12-7  per  cent.,  and  of  the  latter  as 
24'2  per  cent. ;  the  death-rate  being  practicall}^  doubled. 

4.  Influence  of  the  Site  of  the  Amputation. — Amputations 
in  the  upper  limb  are  less  fatal  than  those  in  corresponding 
parts  of  the  loAver  hmb,  and  in  either  limb  the  rate  of 
mortahty  increases  the  nearer  the  amputation  is  to  the  tnmk. 

Tlie  following  table  is  founded  on  the  statistics  collected 
by  Ashhurst  and  others,  and  upon  the  results  of  amputation  as 
shown  in  the  records  of  the  London  Hospital. 

The  figures  are  comparative  only.  The  unit  or  standard  is 
the  mortality  after  amputation  of  the  fingers  or  thumb,  and  is 
here  expressed  by  the  fig-ure  1.  For  example,  the  mortality 
after  amputations  of  the  arm  is  nine  times  greater  than  that 
folloAving  amputation  of  the  fingers  (the  standard),  while  that 
attending  disarticulations  at  the  knee  is  sixteen  times  higher 
than  the  death-rate  of  the  standard  amputation. 


Fingers  or  thumb    .... 

Partial  amputation  of  hand     . 

Amputation  at  wrist-joint 
„  of  forearm 

,,  at  elbow- joint 

„  of  arm       .     .     . 

„  at  shoulder-joint 


Toes 

Partial  amputation  of  foot 
Amputation  at  ankle-joint 

,,  of  leg  .     .     . 

,,  at  knee-joint 

,,  of  thigh    .     . 

,,  at  hip    .     .     . 


2 
7 
5 
11 
16 
21 
24 


317 


CHAPTER    X. 

Amputation  of  the  Fingers  and  Thumb. — General 
Considerations. 

Anatomical  Points. — The  skin  on  the  palmar  aspect  of  the 
fingers  and  the  thumb  is  thick,  dense,  stiff,  and  adherent. 
There  is  very  little  subcutaneous  tissue.  The  palmar  integu- 
ment is  remarkably  sensitive,  especially  that  covering  the  pulp 
of  the  digits. 

The  skin  on  the  dorsum,  on  the  other  hand,  is  thin  and 
loose,  and  beneath  it  is  a  stratum  of  lax  connective  tissue.  Its 
sensibility  is  comparatively  dull. 

The  position  of  the  phalangeal  joints  must  be  clearly 
defined.  It  is  to  be  borne  in  mind  that  the  "  knuckle "  at 
both  the  metacarpo-phalangeal  and  inter-phalangeal  joints  is 
formed  by  the  head  of  the  proximal  bone,  and  that  the 
articular  line  is  therefore  beyond  or  below  the  knuclde. 
Of  the  transverse  folds  across  the  fronts  of  the  fingers 
produced  by  the  joints,  the  highest  is  single  for  the  index  and 
little  finger,  and  double  for  the  other  two.  It  is  placed  nearly 
three-quarters  of  an  inch  below  the  corresponding  joint 
(Fig.  77).  The  middle  folds  are  double  for  all  the  fingers,  and 
are  exactly  opposite  the  first  inter-phalangeal  joints.  The 
lowest  creases  are  single,  and  are  jDlaced  a  little  above 
the  corresponding  joints  (from  1  to  2  m.m.).  There  are  two 
single  creases  on  the  thumb  corresponding  to  the  two  joints, 
the  higher  crossing  the  metacarpo-phalangeal  articulation 
obliquely.  The  free  edge  of  the  web  of  the  fingers,  as 
measured  from  the  palmar  surface,  is  about  three-quarters  of 
an  inch  from  the  metacarpo-jjlialangeal  joints  (Fig.  77). 

All  the  joints  are  supported  by  two  lateral  ligaments  and 
a  glenoid  ligament.  The  former  are  nearer  to  the  palmar 
than   the   dorsal  aspect ;   the   latter   exists  as  a  firm   fibro- 


318 


OPERATIVE    SURGERY. 


cartilaginous  plate,  which  is  attached  mainly  to  the  base  of  che 
distal  bone. 

In   the   metacarpo-phalangeal  joint   of    the    thumb,   t^v  > 
sesamoid  bones  replace  this  hgamentous  palmar  plate. 


Fig.  77.— .SURFACE  MARKINGS  ON  THK  FALSI  OF  THE  HAND.     (The  thick  black  lines 
represent  the  chief  creases  of  the  skin.) 


A  single  epiphysis  exists  for  each  metacarpal  bone  and 
phalanx.  It  forms  tlie  head  of  the  four  inner  metacarpal  bones 
and  the  base  of  the  metacarpal  of  the  thumb  and  of  the 
phalanges  (Fig.  78).     It  joins  the  shaft  at  the  age  of  twenty. 

The  fibrous  sheaths  for  the  flexor  tendons  extend  from  the 
metacarpo-phalangeal  joints  to  the  upper  ends  of  the  third 
phalanges.  The  pulj)  of  the  third  phalanx,  therefore,  rests 
practically  upon  the  periosteum.  Opposite  the  finger-joints 
the  sheaths  are  lax  and  thin.     In  the  rest  of  their  course  they 


AMPUTATION    OF  FINGERS. 


319 


are  dense  and  rigid,  and  when  cut  across  remain,  in  virtue  of 
this  rigidity,  wide  open,  and  form  an  open  channel  which  leads 
into  the  palm  of  the  hand  (Fig.  79). 

There  are  two  synovial  sacs  beneath  the  annular  Hgament 
for  the  flexor  tendons,  one  for  the  flexor 
of  the  thumb,  the  other  for  the  two  flexors 
of  the  fingers.  The  former  extends  up 
into  the  forearm  for  about  l?  inch  above 
the  annular  ligament,  and  follows  the  ten- 
don to  its  insertion.  The  latter  rises  about 
1^  inch  above  the  annular  band,  and 
ends  in  diverticula  for  the  four  fingers. 
The  process  for  the  little  finger  usually 
extends  to  the  insertion  of  the  flexor  pro- 
fundus tendon  m  the  last  phalanx.  The  remaining  three  diver- 
ticula end  about  the  middle  of  the  corresponding  metacarpal 
bones.  The  synovial  sheaths  for  the  digital  part  of  the  tendons 
to  the  index,  middle,  and  ring  fingers  end  above,  about  the 
neck  of  the  metacarpal  bones,  and  are  thus  separated  by  about 
half  an  inch  from  the  great  synovial  sac  beneath  the  annular 
ligament. 

Thus  there  is  an  open  channel  from  the  ends  of  the  thumb 
and  little  finger  to  a  point  in  the  forearm  some  inch  and  a 


Fig.  78.— A  FINGEB 
FLEXED  TO  SHOW  THE 
JOINT  LIXES  AND  THE 
EPIPHYSES. 


Fig.    79. — HORIZONTAL    SECTION   THROUCxH    THE  MIDDLE    OF   THE    SECOND  PHALANX. 

{Tillaux.) 

a.  Flexor  tendon ;    h.  Fibrous  sheath  of  tendon ;    c,  Extensor  tendon ;    d,  Digital 

artery  and  nerve. 


half  above  the  annular  ligament.  Thus  suppuration  in  the 
thumb  and  little  finger  is  apt  to  be  followed  by  abscess  in  the 
forearm,  a  complication  unusual  after  a  like  trouble  in  the 
remaining  fingers. 

The  digital  arteries  are  about  the  size  of  the  posterior 
auricular,  and  run  much  nearer  to  the  palmar  than  the  dorsal 
surface. 


320  OPERATIVE    SUBGEBY. 

The  dorsal  diofital  arteries  of  the  thumb  are  of  good  size, 
but  on  the  fingers  they  appear  as  quite  insignificant  vessels 
■which  can  hardl}^  be  traced  beyond  the  first  phalanx. 

The  Parts  Removed. — Amputations  of  the  fingers  are 
often  of  necessity  imperfect  operations,  and  in  some  traumatic 
cases  represent  little  more  than  a  trimming  of  mangled  parts. 

In  performing  these  operations  every  care  should  be  taken 
to  remove  as  Httle  of  the  digit,  and  especially  of  the  thumb 
and  index,  as  possible.  The  shortest  and  most  ungamly- 
looking  stump  of  the  thumb  or  of  the  forefinger  may  prove  to 
be  of  the  greatest  value. 

A  French  surgeon  has  well  said,  "  Le  pouce  represente  a 
lui  seul  I'un  des  mors  de  la  pince  que  forme  la  main." 

If  the  thumb  or  a  portion  of  it  be  left,  it  is  important  that 
it  should  have  something  with  which  to  come  into  apposition ; 
and  in  fulfilling  this  need  the  slightest  stump  of  the  forefinger 
is  of  considerable  service.  The  little  and  ring  fingers  are  of 
less  importance  provided  that  the  other  digits  remain ;  but  in 
cases  where  the  three  or  the  two  outer  fingers  have  been 
removed,  the  little  finger  or  the  ring  finger  has  been  capable, 
in  conjunction  with  the  thumb,  of  performing  most  valuable 
and  complex  functions. 

A  hand  with  nothing  left  but  the  stumps  of  a  thumb  and 
of  a  little  finger,  is  more  useful  than  the  most  elaborate 
artificial  hmb.  Dr.  Gregory  {Trans.  Avier.  Surg.  Ass.,  vol.  ii., 
page  232)  mentions  the  case  of  a  lad  who  could  hold  a  pen  Avith 
a  hand  of  which  nothing  had  been  saved  but  a  small  part  of 
the  thumb  and  the  metacarpus  and  carpus. 

The  bone  should  always  be  divided  as  low  down  as 
possible.  If  only  the  base  of  the  terminal  phalanx  can  be 
saved,  it  will  secure  for  the  finger  the  attachment  of  the  flexor 
profundus  tendon. 

Amputation  of  the  second  phalanx  should  be  performed 
through  the  bone  whenever  possible.  If  the  upper  half,  or 
even  the  upper  third,  of  the  phalanx  be  left,  some  portion  of 
the  insertion  of  the  flexor  sublimis  wiU  be  saved.  If,  on  the 
other  hand,  disarticulation  is  effected,  the  first  phalanx  is  aj^t 
to  be  left  to  form  a  stump  which  is  stiff  and  incapable  of 
flexion,  and  is  possibly  an  actual  impediment. 

This  evil   may   be  sometimes  avoided  by  including  the 


AMPUTATION   OF   FINGERS.  321 

flexor  tendons  in  the  sutures.  "  In  the  following  special 
cases,"  writes  Mr.  Jacobson  ("Operations  of  Surgery,"  page  4), 
"the  whole  or  part  of  the  first  phalanx  may  be  left,  and  in  all 
of  them  the  severed  flexor  tendons  should  be  carefully  stitched 
with  carbolised  silk  to  the  cut  theca  and  periosteum,  or  into 
the  flaps  themselves,  before  adjusting  these. 

"  1.  In  the  case  of  the  index  flnger  the  proximal  phalanx 
will  be  a  useful  opponent  to  the  thumb,  as  in  holding  a  pen. 

"  2.  In  the  case  of  the  little  flnger,  leaving  the  proximal 
phalanx  will  give  greater  symmetry  to  the  hand  when  this 
is  flexed,  and  it  should  accordingly  be  left  if  the  patient 
desire  it. 

"  3.  In  cases  of  amputation  of  all  the  Angers,  the  proximal 
phalanx  of  one  should,  if  possible,  always  be  left  to  oppose  the 
thumb. 

"  4.  In  the  case  of  a  patient  who  insists  on  having -the  proxi- 
mal phalanx  left,  after  the  risk  of  stiffness  has  been  explained 
to  him,  the  more  care  is  taken  to  fix  the  several  flexors  to 
the  theca  the  more  quickly  the  stump  heals,  and  the  younger 
the  patient  the  greater  will  be  the  movement  gained." 

The  Shaping  of  the  Flaps. — As  the  bones  of  the  finger  are 
comparatively  large  in  relation  to  the  surrounding  soft  parts, 
the  flaps  must  be  cut  comparatively  long.  Thus  a  single  pal- 
mar flap  should  be  equal  to  one  diameter  and  a  half  of  the 
digit.  If  unequal  dorsal  and  palmar  flaps  are  cut,  the  palmar 
flap  should  be  longer  than  the  diameter  of  the  digit,  while  the 
dorsal  flap  should  be  about  the  third  of  the  palmar.  Farabeuf 
gives  these  measurements : — If  the  breadth  of  the  finger  be 
16  m.m.,  a  single  palmar  flap  should  be  24  m.m.  in  length.  If 
unequal  flaps  be  made,  the  palmar  should  measure  18  m.m. 
and  the  dorsal  6  m.m. 

Flaps  should  be  so  cut  that  the  cicatrix  is  removed  from 
pressure.  The  scar  therefore  should  not  be  on  the  extremity 
of  the  stump  nor  upon  its  palmar  aspect.  In  other  words, 
the  scar  is  most  conveniently  placed  when  placed  upon  the 
dorsum. 

For  this  reason  a  single  palmar  flap  or  a  predominating 
palmar  flap  (when  two  are  cut)  represents  the  best  method  in 
amputation  through  the  fingers.  The  stump  which  results  is 
covered  with  firm  and  vascular  skin,  well  able  to  withstand 


322  OPERATIVE    8URGEBY. 

pressure,  and  is  indued  witli  tlie  remarkable  sensibility  of  the 
part.  A  dorsal  flap  involves  a  covering  for  the  stump  which 
is  thin,  ill  supplied  with  blood,  Httle  able  to  withstand  pressure, 
and  of  shght  sensibility. 

The  oval  method  provides  a  stump  with  the  good  qualities 
furnished  b}^  the  palmar  flap. 

The  Closing  of  the  Fibrous  Sheaths. — The  fibrous  sheaths 
for  the  flexor  tendons  when  cut  across,  as  in  these  operations, 
form  rigid  tubes  along  which  pus  may  pass  and  enter  the  palm 
of  the  hand.  The  flexor  tendons  retract  after  division,  but  the 
sheaths  do  not,  so  there  is  provided  in  the  depths  of  the  stump 
a  natural  drainage-tube,  the  remote  end  of  which  leads  into 
the  palm ;  if  no  suppuration  occurs,  this  hidden  channel  may 
produce  no  evil.  It  is  soon  occluded  and  unable  to  be  harmful. 
If  the  stump,  however,  does  suppurate,  as  is  so  common  after 
crushes  of  the  fingers,  the  pus  can  find  its  way  with  great 
readiness  into  the  rigid  patent  fibrous  tube,  and  then  ensues 
that  deep-seated  suppuration  in  the  stump  and  in  the  palm 
which  is  by  no  means  uncommon  after  the  present  series  of 
operations.  When  such  a  complication  occurs,  the  pus  can 
be  squeezed  out  of  the  sheath,  and,  if  the  flaps  have  given 
way,  can  be  seen  to  come  from  the  tube  itself 

To  avoid  this  serious  hindrance  to  healing,  the  fibrous 
sheath  should  be  closed  when  possible  after  all  amputations 
of  the  fingers  and  thumb.  Over  the  terminal  phalanx,  and 
over  the  joint  between  the  middle  and  termmal  phalanges, 
there  is  no  fibrous  sheath.  In  front  of  the  metacarpo-phalan- 
geal  joint  it  is  scarcely  evident.  Over  the  first  and  second 
(proximal  and  middle)  phalanges,  and  in  front  of  the  joint 
between  these  bones,  the  fibrous  sheath  is  well  marked,  and 
appears  as  a  rigid  tube  when  cut  across. 

As  the  sheath  crosses  the  metacarpo-phalangeal  and  first 
inter-phalangeal  joints,  it  is  adherent  to  the  glenoid  liga- 
ment, and  is  easily  closed  by  two  fine  catgut  sutures  passed 
vertically,  i.e.,  from  the  dorsal  to  the  palmar  wall. 

Opposite  the  shafts  of  the  first  and  second  phalanges,  how- 
ever, there  is  much  difficulty  in  effecting  this  closure,  since 
the  sheath  is  united  to  the  periosteum,  and  that  membrane  is 
very  thin.  In  these  situations  the  periosteum  should  be 
stripped  up  a  little  from  the  palmar  aspect  of  the  bone,  and 


AMPUTATION   OF   FINGEBS.  '  823 

the  orifice  of  the  tube  secured  by  two  fine  sutures  passed 
either  vertically  or  transversely,  as  may  appear  the  more  con- 
venient. This  stripping  oft*  of  periosteum  should  be  effected 
before  the  bone  is  divided. 

The  Instruments  required. — Narrow,  slender,  and  strong 
scalpels,  the  blades  of  which  should  be  equal  in  length  to 
about  one  diameter  and  a  half  of  the  digit  to  be  removed. 
(A  fine  scalpel  with  a  cutting  edge  one  inch  in  length  will 
serve  admirably  for  most  amputations  of  the  fingers.  The 
"  finger  knife  "  of  the  instrument-makers  is  an  absurd  instru- 
ment. Its  blarle  is,  accordinsr 
to  one  catalogue,  nearly  three 
inches  in  length.  Such  large 
knives  were  at  one  time  em- 
ployed, and  m  Fergusson's 
figure  of  an  amputation 
through  the  second  phalanx, 
the  knife  depicted  has  a  blade 
that  must  have  been  some 
four  inches  long.)     A  fine  key-     Fig-  so. --the  mode  of  holding  the 

*^  '  n      T>  FINGER   DITIING    DISARTICULATION    OF 

hole-saw   or  very  small  JBut-       nm  last  phalanx. 
cher's-saw.  Bone  forceps.  Dis- 
secting and  artery  forceps.     Tapes  to  hold  aside  the  fingers. 
Scissors,  needles,  etc. 

Position. — The  surgeon  sits  with  the  patient's  hand  before 
him.  The  limb  should  be  in  the  position  of  pronation  while 
dorsal  incisions  and  flaps  are  being  made,  and  in  supination 
during  the  fashioning  of  palmar  flaps. 

In  the  oval  operation  the  limb  may  be  kept  pronated 
throughout,  and  disarticulation  is  in  any  case  conveniently 
effected  in  that  position. 

The  surgeon  holds  the  tinger  to  be  removed  with  his  left 
hand,  placed  m  the  supine  position  (Fig.  80).  An  assistant  is 
placed  opposite  to  the  surgeon.  He  holds  the  patient's  hand 
in  the  required  position,  and  keeps  the  sound  digits  out  of  the 
way. 


v2 


324 


CHAPTER    XI. 

Amputation  or  Disarticulation  of  the  Phalanges  of 
THE  Fingers. 

These  operations  include  amputations  through  the  proxi- 
mal, middle,  or  terminal  phalanges,  and  disarticulations  at  the 
first  or  second  inter-phalangeal  joints.  An  amputation  through 
the  terminal  phalanx  can  scarcely  claim  to  be  a  defined 
operation. 

Four  methods  will  be  described — 

1.  By  single  j)almar  flap. 

2.  By  unequal  dorsal  and  palmar  flaps. 

3.  By  single  external  flap. 

4.  By  lateral  flaps. 

1.  By  Single  Palmar  Flap. — Illustrated  by  the  removal 
of  the  last  phalanx  at  the  joint. 

Hold  the  digit  between  the  left  thumb  and  forefinger  (the 
thumb  upon  the  pulp  of  the  digit,  the  forefinger  on  the  nail). 
Ascertain  the  position  of  the  joint.  Commence  the  incision 
upon  one  side  of  the  finger  oj)posite  to  the  joint-line  and  mid- 
way between  the  dorsal  and  palmar  asj)ects  of  the  digit. 
(>S'ee  Comment  on  these  operations,  page  327,  paragraph  1.) 
^lark  out  the  palmar  flap  by  an  incision  which  involves  the 
skin  only.  This  flap  will  include  the  greater  part  of  the  pulp 
of  the  finger  (Fig.  81).  Now  carry  the  incision  to  the  bone 
throughout,  and  dissect  up  the  flap  so  freed,  including  in  it 
everything  down  to  the  bone.    {See  Comment,  page  327,  par.  2.) 

Let  the  patient's  finger  be  now  flexed,  and  make  the  dorsal 
incision.  This  incision  is  carried  transvcrsol}^  across  the  finger 
at  the  level  of  the  base  of  the  distal  phalanx.  Retract  the 
soft  parts  a  little  and  open  the  joint.  (*S'ee  Comment,  page 
327,  par.  3.) 

Divide  the  lateral  ligaments.  Nothing  now  connects  the 
phalanx  with  the  rest  of  the  finger  but  the  flexor  profundus 


AMPUTATION   OF   FINGERS.  325 

tendon  and  the  glenoid  ligament.  Put  the  terminal  phalanx 
in  the  position  of  extreme  extension  and  divide  these  two 
structures,  by  cutting  from  below  up  against  the  base  of  that 
phalanx.  (See  Comment,  page  327,  par.  4.)  No  vessels  re- 
quire to  be  secured,  and  the  tendon  sheath  is  not  opened. 

2.  By  Unequal  Dorsal  and  Palmar  Flaps. — Illustrated 
by  disarticulation  at  the  first  inter-phalangeal  joint. 

The  palmar  flap  should  exceed  a  little  in  length  the  dia- 
meter of  the  digit  at  the  joint- 
line.     The  dorsal  flap  is  one-  b 
third  the  length  of  the  palmar                      /-^-^iT^^^^^^IZ^IIIi:! 
(page  321).    ^(See  Fig.  81,  c.)                x^^'^^^^^dH^ 

Ascertain  the   line   of  the       y'^^'^^s^^^^f^^. 

Hold  the  flnger  in  the  posi-     ^^-^Ji^^^ 

x-  ,•     ""  1  1  .       Fis.  81. — A  and  B,   Disarticulations  by 

tion  of  pronation,  and  mark  out       f^^.^^  ^^^^^^^  ^^^ .  c,  Amputation  by 

the  flaps  by  skin  incisions.      The  unequal  dorso-palmar  tiaps. 

flaps  should  be  squarely  cut. 

The  lateral  incisions  should  be  placed  midway  between  the 
dorsal  and  palmar  surfaces,  and  should  be  commenced  just 
above  the  joint-lino. 

Carry  the  lateral  cuts  to  the  bone.  Flex  the  finger  strongly 
and  carry  the  dorsal  incision  to  the  bone. 

Dissect  up  the  dorsal  flap,  including  in  it  all  the  soft  parts 
to  the  bone.     Open  the  joint  from  the  dorsal  aspect. 

Dissect  up  the  palmar  flap,  dividing  the  flexor  tendon 
at  the  end  of  the  flap  while  the  finger  is  in  the  extended 
[josition.     This  flap  also  includes  all  the  soft  parts  to  the  bone. 

When  the  joint  is  reached,  divide  the  lateral  ligaments, 
separate  the  glenoid  ligament  from  the  base  of  the  second 
phalanx,  and  the  disarticulation  is  completed.  {See  Comment, 
page  327,  par.  4.) 

The  tendon  sheath  must  be  closed  (page  322). 

If  an  attempt  is  to  be  made  to  secure  the  flexor  tendons 
for  reasons  already  given  (page  321),  the  divided  extremity  of 
each  (or  the  free  end  of  the  flexor  profundus  tendon  only)  is 
attached  to  the  remains  of  the  fibrous  sheath  and  to  the 
glenoid  hgament  (which  is  left  in  the  stump).  The  tendons 
are  thus  made  to  occupy  the  fibrous  sheath,  which  is  readily 
closed  around  them. 


326  OPERATIVE    SURGE  BY. 

No  vessels  will  probably  require  ligature.  The  dorsal 
arteries  are  cut  at  the  end  of  the  palmar  flap. 

3.  By  Single  External  Flap. — Illustrated  by  disarticulation 
at  the  tirst  mter-phalangeal  joint. 

The  flaps  are  fashioned  as  shown  in  Fig.  82,  a.  The  two 
longitudinal  incisions  are  in  the  centre  of  the  dorsal  and 
palmar  surfaces  respectively,  and  both  commence  just  abovo 
the  level  of  the  joint. 

The  outer  transverse  incision — marking  the  extremity  of 
the  external  flap — is  opjDosite  the  centre  of  the  second  phalanx. 
The  inner  transverse  incision  is  opposite  the  joint. 

The  external  flap,  having  been  marked  out,  is  dissected  up. 
It  contains  aU  the  soft  parts  down  to  the  tendons. 

The  finger  having  been  fuUy  flexed,  the  joint  is  opened 
from  the  dorsum  by  cutting  through  the  extensor  expansion. 

The  lateral  Hgaments  of  the  joint  are  now  cut. 

The  finger  is  then  placed  in  the  position  of  extension,  and 
the  flexor  tendons  and  the  attachment  of  the  glenoid  ligament 
are  divided  from  below  up  against  the  base  of  the  second 
phalanx. 

The  tendons  and  the  tendon-sheath  may  be  dealt  with 
as  in  the  previous  operation. 

The  digital  vessels  are  divided  in  the  transverse  incisions, 
but  will  probably  not  require  ligatures. 

4.  By  Lateral  Flaps. — Illustrated  by  amputation  through 
the  second  phalanx. 

The  external  and  internal  flaps  are  of  equal  size  and  do  not 
equal  in  length  the  diameter  of  the  finger  (Fig.  82,  b).  The 
dorsal  and  palmar  incisions  are  median.  The  flaps  are  squarely 
cut  and  contain  all  the  soft  parts  down  to  the  tendons.  The 
flexor  profimdus  tendon  and  the  expansions  from  the  flexor 
subhmis  and  extensor  tendons  are  divided  circularly  at  the 
saAv-line.  The  bone  is  divided  with  a  fine  saw.  (See  Connnent, 
page  328,  par.  5.) 

The  digital  arteries  are  cut  at  the  extremities  of  the  flaps. 

Appreciation  of  the  above  Operations. — Of  these  four 
procedures  the  two  first-named  are  the  best.  The  importance 
of  the  palmar  flap  has  already  been  dwelt  upon  (page  321). 

The  third  method — that  by  an  external  flap — answers 
well  when  the  tissues  upon  the  palmar  and  inner  sides  of  the 


AMPUTATION    OF   FINGERS.  327 

finger  are  damaged.  It  is  peculiarly  well  adapted  for  the 
index  finger. 

A  precisely  similar  single  flap  may  be  cut  from  the  inner 
side  of  the  finger,  but  in  the  case  of  the  index  the  cicatrix 
would  be  very  inconveniently  placed.  The  internal  flap 
method  is  well  suited  to  some  amputations  of  the  inner 
fingers. 

The  amputation  by  the  lateral  method  produces  well- 
nourished  flaps  and  a  shapely  stump,  but  the  cicatrix  is 
inconveniently  placed ;  and  if  the  healing  be  imperfect,  there  is 
a  disposition  for  the  bone  to  project  between  the  flaps. 

Equal  palmar  and  dorsal  flaps  produce  a  stump  with  the 
cicatrix  at  its  extremity. 

The  oval  method  is  not  well  adapted  for  these  amputa- 
tions. If  applied  to  effect  a  disarticulation,  the  dorsal 
incision  should  commence  just  above  the  joint,  and  the 
circular  incision  be  about  the  centre  of  the  phalanx  below 
(Fig-.  82,  c).  The  resulting  stump  is  clumsy,  and  the  cicatrix 
is  ill-placed. 

Comment  upon  the  above  Operations. — 1.  A  longituduial 
cut  made  in  the  centre  of  the  lateral  surface  of  the  finger 
— i.e.,  midway  between  the  dorsum  and  the  palmar  aspect — 
will  not  wound  the  digital  artery,  which  will  be  found  intact 
in  the  palmar  flap. 

2.  In  no  operations  upon  the  fingers  is  it  well  to  cut  the 
flaps  by  transfixion.  In  cutting  a  palmar  flap  by  this  means 
there  is  danger  of  slitting  up  the  digital  arteries.  The  flap, 
moreover,  is  apt  to  be  pointed  and  scant}',  and  to  contain 
fragments  of  tendon. 

3.  In  disarticulations  a  very  slight  dorsal  flap  is  a  decided 
advantage,  and  allows  a  better  covering  to  be  provided  for 
the  head  of  the  bone. 

4.  Disarticulation  may  be  effected  in  finger  amputations 
by  cutting  from  above  downwards.  The  joint  is  exposed  from 
the  dorsum,  the  finger  being  fuUy  flexed :  the  lateral  liga- 
ments are  divided  ;  the  knife  is  then  passed  behind  the  base  of 
the  distal  bone,  and  is  made  to  cut  its  way  outwards  in 
the  direction  of  the  palmar  surface. 

This  method  is  not  so  precise  as  that  indicated  in  the 
formal   accoiuit   of  the   operation.      The   base  of  the  distal 


328  OPERATIVE    SVBGEBY. 

phalanx  often  offers  an  obstacle  to  the  passage  of  the  knife ; 
the  glenoid  Hgament — which  should  be  left  in  the  stump — is 
apt  to  be  cut  away,  and  damage  may  be  inflicted  upon  the 
tissues  of  the  palmar  flap. 

5.  A  Yery  line  saw  is  much  to  be  preferred  to  the  bone- 
forceps  for  dividing  the  phalanx.  The  forceps  are  apt  to 
splinter  the  bone,  especially  in  the  fingers  of  well-developed 
adults  and  in  old  persons  (page  306). 


329 


CHAPTER    XII. 

Disarticulation   of   Fingers   at   the    Metacarpo- 
phalangeal  Joints. 

These  operations  are  performed  with  great  frequency  and 
represent  the  most  common  amputations  of  the  fingers. 

It  is  well  that  the  cicatrix  should  come  upon  the  dorsum 
of  the  hand,  and  that  the  operation  should  be  so  carried  out 
as  to  involve  the  least  possible  interference  with  the  palm. 

The  following  methods  will  be  described : — 

1.  By  the  oval  method. 

2.  By  lateral  flaps. 

3.  Operations  for  the  forefinger. 

4.  Operations  for  the  little  finger. 

1.  By  the  Oval  or  Racket  Method. — The  method  here 
described  corresponds  to  the  French  incision  en  croupiers, 
and  does  not  exactly  accord  with  either  the  orthodox  racket 
incision  or  the  unmodified  oval  operation. 

The  dorsal  incision  is  commenced  just  above  the  head  of 
the  metacarpal  bone  {i.e.,  opposite  to  its  neck),  and  is  carried 
down  in  the  median  line  of  the  finger  until  it  has  passed  the 
base  of  the  phalanx. 

The  cut  now  divides,  and  its  limbs  sweep  obliquely  across 
each  side  of  the  root  of  the  finger.  They  are  joined  on  the 
palmar  aspect  by  a  transverse  incision,  which  exactly  follows 
the  crease  between  the  finger  and  the  palm,  and  is  therefore 
level  with  the  free  margin  of  the  web  (Fig.  82,  f). 

The  surgeon,  having  made  out  the  position  of  the  joint, 
holds  the  finger  in  the  prone  position  in  his  left  hand.  An 
assistant  steadies  the  hand  and  keeps  the  other  fingers  out  of 
the  way. 

Throughout  the  whole  operation  the  hmb  is  kept  in  the 
prone  position. 


33U 


OPERATIVE    SURGERY. 


The  knife  is  entered  upon  tlie  dorsum,  and  is  carried  first 
across  one  side  of  the  root  of  the  finger  and  then  across  the 
other  side.  The  incision  is  completed  by  the  transverse 
palmar  cut.  Three  separate  cuts  with  the  knife  are  therefore 
required 

There  is  no  object  in  attempting  to  make  the  entire  inci- 
sion with  one  sweep  of  the  scalpel. 

The  incision  should  at  first  involve  the  skin  only. 
The  finger  is  now  extended  to  its  utmost,  and  the  palmar 

incision  is  carried  to  the 
bone,  the  flexor  tendons 
being  thus  stretched  and 
divided. 

The  finger  being  then 
turned  to  one  or  other 
side,  the  lateral  incisions 
— on  each  aspect  of  the 
root  of  the  finger — are 
carried  to  the  bone.  In 
this  way  the  digital  ar- 
teries are  cleanly  divided, 
and  the  expansions  from 
the  lumbricals  and  inter- 
ossei  are  cut. 

The  assistant  now 
takes  the  finger,  while  the 
surgeon  dissects  back  the 
flaps,  as  far  as  the  joint- 
line,  with  the  aid  of 
forceps. 

The  wrist  and  finger 
being  fully  extended,  the 
operator  once  more  takes 
hold  of  the  digit  and  pro- 
ceeds to  open  the  joint 
from  the  palmar  aspect. 
He  cuts  the  glenoid  liga- 
ment transversely  against  the  base  of  the  phalanx,  divides  the 
lateral  ligaments,  and  finally  completes  the  operation  by 
cutting  the  extensor  tendon.     Disarticulation  may  be  effected 


Fig.  82. — A,  Disarticulation  by  single  external 
flap ;  B,  Aminitation  by  Literal  flap.s ;  c, 
Disarticulation  by  oval  or  racket  incision ; 
n,  Modified  racket  incision  for  index  finger  ; 
E,  Circular  method,  with  vertical  dorsal  cut ; 
K,  Incision  en  croiipiorc ;  g,  Interno-palmivr 
flap  method  for  little  finger;  H,  Disarticula- 
tion by  single  palmar  flap ;  i,  Disaiticula- 
tion  by  racket  incision  ;  K,  Amputation  of 
the  fingers  with  tlieir  metacarpal  bones ; 
I-,  Circular  disarticulation  at  the  wrist. 


AMPUTATION   OF   FINGERS.  331 

from  the  dorsum,  but  it  renders  the  section  of  the  glenoid 
ligament  a  little  less  easy. 

The  synovial  sheath  for  the  flexor  tendons  may  be  closed. 

The  glenoid  ligament  remains  in  the  stump. 

The  two  palmar  digital  arteries  will  require  to  be  ligatured 
or  twisted. 

The  cicatrix  is  vertical — i.e.,  in  the  long  axis  of  the  limb. 

2.  By  Lateral  Flaps. — -The  method  here  described  is  that 
often  known  as  Lisfranc's  operation. 

The  flaj)s  are  of  equal  size  and  are  a  little  rounded.  The 
base  of  each  corresponds  to  the  joint-line,  the  free  extremity 
of  each  to  the  level  of  the  Aveb.  The  median  dorsal  cut 
commences  just  above  the  metacarpo-phalangeal  joint.  The 
palmar  median  incision  extends  into  the  palm  up  to  the 
level  of  that  joint  (Fig.  83,  b). 

The  "modus  operandi  is  as  follows : — 

The  surgeon  marks  out  both  the  flaps  by  skin  incisions. 
He  then  dissects  up  one  of  the  flaps  (that  to  his  right)  until 
the  joint  is  reached.  This  flap  includes  all  the. soft  parts 
down  to  the  bone,  and  the  digital  artery  is  divided  at  its  free 
extremity. 

He  then  opens  the  joint  by  cutting  the  exposed  lateral 
ligament,  viz.,  that  to  his  (the  surgeon's)  right. 

Holding  the  knife  vertically,  with  the  blade  directed 
upwards,  the  operator  passes  it  across  the  joint,  cuts  the 
opposite  lateral  ligament,  and  then  fashions  the  other  lateral 
flap  (that  to  the  surgeon's  left)  by  cutting  from  within  out- 
wards. 

All  the  tendons  are  divided  at  the  joint-level,  and  are 
severed  as  the  knife  is  passed  transversely  across  the 
articulation. 

The  digital  vessels  are  cut  at  the  free  end  of  each  flap. 

3.  Modified  Operations  for  the  Forefinger. — In  order 
that  the  cicatrix  may  not  be  exposed  to  pressure  when  the 
thumb  is  opposed  to  the  stump,  or  when  anything  is  being 
held  in  the  hand,  the  following  modified  procedures  may  be 
carried  out : — 

(a)  By  the  racket  incision,  with  the  vertical  cut  placed 
upon  the  side  of  the  index  nearest  to  the  middle  finger,  and 
with  the  incision  carried  a  little  further  on  the  radial  than 


332  OPERATIVE    SURGERY. 

on  the  ulnar  side  of  the  digit.  In  the  latter  situation  it 
corresponds  to  the  web  (Fig.  82,  d). 

Qj)  By  imequal  lateral  flaps,  the  external  flap  being  the 
larger. 

(c)  By  the  externo-palmar  flap  of  Farabeuf.  The  incision 
commences  at  the  jomt-line,  just  to  the  radial  side  of  the 
extensor  tendon.  It  is  carried  down  along  the  outer  side  of 
the  dorsum  nearly  as  far  as  the  centre  of  the  shaft  of  the 
phalanx.  It  is  then  made  to  sweep  across  the  palmar  aspect 
of  the  finger  to  the  web.  From  the  web  it  passes  by  the 
shortest  route  to  the  point  at  which  the  incision  commenced 
(Fig.  83,  A). 

The  large  flap  is  dissected  up,  carrying  with  it  all  the  soft 
parts  down  to  the  bone.  The  tendons  are  divided  and  dis- 
articulation effected  in  the  usual  way. 

4.  Modified  Operations  for  the  Little  Finger. — These 
have  for  their  object  the-  removal  of  the  cicatrix  from  an 
exposed  position. 

{a)  By  a  racket  incision,  with  the  vertical  cut  placed 
upon  the  side  of  the  digit  nearest  to  the  ring-finger,  and  with 
the  incision  carried  a  little  further  on  the  ulnar  than  on  the 
radial  side  of  the  finger. 

(6)  By  unequal  lateral  flaps,  the  internal  being  the  larger. 

(c)  By  the  interno-palmar  flap  of  Farabeuf  (Fig.  82,  g). 
It  corresponds  to  the  flap  already  described  as  employed  for 
the  index  finger,  with  the  necessary  difference  that  the  posi- 
tion of  the  incisions  is  transposed. 

Comment  on  the  above  Operations. — In  all  these  disarticu- 
lations, the  head  of  the  metacarpal  bone  should  be  spared 
whenever  possible. 

It  is  unreasonable  to  sacrifice  it  simply  on  the  ground 
that — in  a  particular  case — the  covering  of  soft  parts  is 
scanty.  It  is  better,  in  such  an  instance,  that  the  necessarily 
gaping  wound  should  be  allowed  to  granulate  over  than  that 
the  end  of  the  bone  should  be  removed. 

It  is  still  more  unreasonable  to  sacrifice  it  on  the  ground 
that  its  removal  improves  the  aspect  of  the  nnitilated  hand. 
The  appearance  of  the  part  may  certainly  be  improved  at  the 
moment  of  the  opcratif»n,  but  in  the  course  of  time  the  un- 
naturally  narrow    extremity   does    not   compare   favourably 


AMPUTATloy    OF    FINGERS.  333 

with  the  hand  marked  by  an  unduly  wide  gap  between  the 
lingers. 

The  head  of  the  bone,  if  left,  appears  to  waste.  The  soft 
parts  about  it  certainly  waste  ;  and  if  the  hand  be  inspected 
six  months  after  the  disarticulation,  it  will  seldom  be  evident 
that  the  removal  of  the  head  of  the  bone  would  have  led  to 
an  improvement  in  the  appearance  of  the  part. 

The  excision  of  the  head  weakens  the  hand  greatly,  an 
effect  due,  probably,  to  a  severing  of  the  connections  of  the 
transverse  ligament.  Its  removal  involves,  moreover,  an 
undesirable  opening  up  of  the  tissues  of  the  palm. 

Of  the  two  operations  first  described,  the  better  is  un- 
doubtedly that  by  the  racket  incision.  The  cicatrix  in  this 
operation  is  well  placed,  and  the  tissues  of  the  palm  are  not 
disturbed.  The  edges  of  the  wound  come  fairly  well  together, 
but  a  httle  pocket  is  apt  to  be  left  in  the  palmar  tissues  just 
in  front  of  the  head  of  the  metacarpal  bone,  in  which  pouch 
pus  may  collect. 

The  operation  by  lateral  flaj^s  has  the  advantages  of  afford- 
ing a  good  covermg  to  the  bone,  a  wound  that  can  be  neatly 
approximated,  without  allowing  any  "  pocket "  to  be  formed, 
and  consequently  good  drainage.  It  has  two  great  drawbacks, 
however :  the  cicatrix  is  carried  into  the  palm,  and  the  tissues 
are  of  necessity  opened  up. 

The  method  by  means  of  a  circular  incision  at  the  level  of 
the  w^eb,  with  a  median  dorsal  cut  (Fig.  82,  e),  affords  a  most 
excellent  covering  to  the  bone,  but  it  provides  a  somewdiat 
clumsy  stump. 

The  various  operations  for  the  index  and  little  fingers 
call  for  no  especial  comment.  Farabeuf  s  methods  by  intero- 
palmar  or  externo-palmar  flaps  are  probably  the  best,  while 
the  method  of  unequal  lateral  flaps  is  the  least  to  be  advised. 


334 


CHAPTER    XIII. 

Amputations  and  Disarticulations  of  the  Thumb. 

In  performing  an  operation  through  the  first  or  the  second 
phalanx,  or  in  disarticulating  at  the   inter-phalangeal  joint, 

one  or  other  of  the  methods 
already  described  in  Chap- 
ter XL  may  be  employed 
(Fig.  82,  H  and  Fig.  83,  c). 
The  comments  applied 
to  these  operations  apply 
equally  when  they  concern 
the  thumb.  In  any  am- 
putation below  the  inter- 
phalangeal  joint  the  sheath 
for  the  flexor  tendon  should 
be  closed.  There  are  four 
digital  arteries  to  the 
thumb,  and  two  at  least  of 
these  will  probably  need  to 
be  secured. 

Disarticulation  at  the 
Metacarpo- phalangeal 
Joint. — It  may  be  remem- 
bered that  the  extensor 
primi  internodii  pollicis, 
the  abductor  and  the  ad- 
ductor pollicis,  and  the 
flexor  brevis  polhcis,  all 
find  insertion  into  the  baeo- 
of  the  first  phalanx. 

The  methods  described 
in  the  previous  chapter  apply  in  general  terms  to  this  dis- 


Fig.  83.— A,  Disarticulation  by  special  ex- 
terno-palmar  flap  ;  B,  Disarticulation  by 
lateral  flajis  ;  C,  Amputation  by  ujie(iual 
(loi'KO-palniar  flaps;  D,  Disarticulation  by 
obliijue  iialniar  Hap  ;  K,  Disarticulation  of 
the  ring  finger,  with  its  metacarpal  bone, 
by  racket  incision  ;  F,  Same  operation  upon 
the  little  finger  ;  G,  Dubrueil's  disarticula- 
tion at  the  wrist. 


AMPUTATION   OF    THUMB.  335 

articulation.     The  two  most  suitable  operations  are  the  fol- 
lowing : — 

1.  By  the  Racket  Incision. — The  incision  commences 
upon  the  dorsum,  opposite  the  neck  of  the  metacarpal  bone, 
and  is  continued  down  along  the  line  of  the  extensor  tendon 
until  the  base  of  the  first  phalanx  is  passed.  Here  the  incision 
divides  to  form  the  oval,  the  palmar  cut  crossing  the  thumb 
transversely  about  opposite  to  the  centre  of  the  shaft  of  the 
phalanx  (Fig.  82,  i). 

The  steps  of  the  operation  have  been  already  described 
(page  329).     Disarticulation  may  be  effected  from  the  dorsum. 

The  two  extensor  tendons  are  divided  opposite  to  the  joint- 
line.  The  flexor  longus  poUicis  tendon  may  be  severed 
opposite  to  the  palmar  incision,  and  the  extremity  of  the 
tendon  may  be  attached  to  the  sesamoid  bones.  The  latter 
structures  should  be  carefully  detached  from  the  base  of  the 
phalanx  and  are  left  in  the  stump. 

The  sheath  for  the  long  flexor  tendon  should  be  entirely 
closed.  Two  or  more  digital  vessels  will  probably  require 
ligatures, 

2.  By  Oblique  Palmar  Flaj). — This  is  Farabeufs  method. 
It  is  most  excellent  in  cases  where  the  tissues  permit  of  so  large 
a  flap  being  cut. 

The  dorsal  incision  is  U-shaped,  the  concavity  being 
towards  the  nail,  and  the  bend  of  the  U  opposite  to  the  joint- 
line. 

The  palmar  incision  is  U-shaped,  the  convexity  being  to- 
wards the  nail,  and  the  bend  reaching  nearly  to  the  inter- 
digital  fold  in  the  skin.  The  lines  of  the  cut  follow  the  lateral 
borders  of  the  thumb  (Fig.  83,  d).  The  flap  is  dissected  up 
in  the  usual  way.  The  extensor  tendons  are  divided  oppo- 
site to  the  joint,  and  the  long  flexor  about  the  middle  of  the 
phalanx.  The  operation  is  finished  in  the  manner  already 
described. 


326 


CHAPTER    XIV. 

Amputations  of  the  Fingers  and  Thumb,  together  with 
Portions  of  the  Metacarpus. 

These  operations  include  the  partial  or  complete  removal 
of  one  or  more  metacarpal  bones,  together  with  the  correspond- 
ing digit  or  digits.  They  are  seldom  performed  in  their 
entirety  in  actual  practice.  There  are  but  few  conditions  in 
either  injury  or  disease  which  could  render  them  possible. 
The  least  infrequent  of  these  operations  concern  the  amputa- 
tion of  the  thumb,  with  its  metacarpal  bone,  and  the  removal 
of  crushed  fingers,  together  with  such  part  of  the  metacarpus 
as  is  hopelessly  damaged. 

As  dead-house  operations,  the  procedures  here  described 
form  very  admirable  exercises. 

In  this  part  of  the  hand  the  rule  still  holds  good  that 
ever}''  portion  and  fragment  of  tissue  should  be  spared  when- 
ever possible. 

Anatomical  Points. — The  main  dangers  of  these  operations 
consist  in  possible  damage  inflicted  upon  the  tissues  of  the 
palm,  in  wounding  the  deep  palmar  arch  or  the  termination 
of  the  radial  artery,  and  in  opening  up  the  general  synovial 
sac  of  the  caq^us,  or  the  scarcely  less  important  synovial  sac 
about  the  flexor  tendons  beneath  the  annular  ligament. 

The  surface  markings  on  the  palm  of  the  hand  should  be 
called  to  mind,  together  with  their  relations  to  the  metacarpal 
bones  and  the  palmar  arches  (Fig.  77).  The  great  crease 
produced  by  the  apposition  of  the  thumb  is  very  noteworthy. 
The  lowest  transverse  crease  on  the  palm  crosses  the  necks 
of  the  metacarpal  bones,  and  indicates  pretty  nearly  the  upper 
limits  of  the  synovial  sheaths  for  the  flexor  tendons  of  the 
three  outer  lingers.  A  little  way  below  this  fold  the  palmar 
fiiscia  breaks  uj)  into  its  four  slips,  and  midway  between  the 


AMPUTATION    OF   METACARPUS.  337 

fold  and  the  webs  of  the  fingers  He  the  metacarpo-phalangeal 
joints. 

The  aspect  of  the  carpo-metacarpal  line  of  joints — from 
the  dorsum — is  to  be  observed  ;  the  saddle-shaped  surface  of 
the  base  of  the  first  metacarpal  bone  as  it  articulates  with  the 
trapezium  ;  the  V-shaped  articular  line  between  the  meta- 
carpal of  the  index  and  the  trapezoid;  the  remarkable 
projection  (styloid  process)  from  the  base  of  the  third  meta- 
carpal bone  at  its  dorsal  and  radial  aspect,  and  the  compara- 
tive simplicity  of  the  joints  connecting  the  two  inner  bones 
with  the  unciform. 

The  base  of  the  metacarpal  bone  of  the  thumb  is  formed 
by  an  epiphysis  which  joins  the  shaft  at  about  twenty. 

A  separate  and  isolated  synovial  cavity  separates  both  the 
first  metacarpal  and  the  fifth  from  their  respective  carpal 
bones.  The  remaining  metacarpals  are  separated  from  the 
carpus  by  the  common  synovial  sac  of  the  hand. 

The  joint  between  the  thumb  and  the  trapezium  is  pro- 
vided with  a  distinct  capsule. 

The  bases  of  the  four  inner  metacarpals  are  united  by 
transverse  dorsal,  palmar,  and  interosseous  ligaments. 

A  strong  and  special  interosseous  band  passes  between  the 
OS  magnum  and  unciform  and  the  bases  of  the  third  and 
fourth  metacarpal  bones. 

To  the  base  of  the  first  metacarpal  is  attached  the 
extensor  ossis  metacarpi  pollicis ;  to  the  base  of  the  second 
the  extensor  carpi  radialis  longior  and  the  flexor  carpi 
radialis ;  to  the  base  of  the  third  the  extensor  carpi  radialis 
brevior  ;  and  to  the  base  of  the  fifth  bone  the  extensor  carpi 
ulnaris  and  some  fibres  of  the  flexor  carpi  ulnaris. 

To  the  shafts  of  all  the  bones  some  portions  of  the  inter- 
ossei  muscles  are  attached,  and  into  the  shafts  of  the  meta- 
carpals of  the  thumb  and  little  finger  are  inserted  in  addition 
the  corresponding  opponens  muscle. 

The  joint  of  the  thumb  is  easily  defined  on  movement. 
In  removing  the  metacarpal  bone  of  that  digit,  the  details  of 
the  tahatiere  anatomique  should  be  called  to  mind.  The 
space  so  named  is  bounded  by  the  extensor  secmidi  internodii 
pollicis  on  the  one  side,  and  the  extensores  ossis  metacarj^i 
and  primi  internodii  on  the  other. 


338  OFEHATIVE   subgeby. 

In  its  floor  are  the  scaphoid,  the  trapezium,  and  the  carpo- 
metacarpal joint  of  the  thumb.  The  extensor  secundi  tendon 
just  crosses  the  apex  of  the  first  interosseous  space.  The 
radial  artery  runs  over  the  floor  of  the  tabatiere  and  passes 
through  the  apex  of  the  interspace  to  reach  the  palm. 

The  position  of  the  synovial  sheaths  of  the  flexor  tendons 
has  been  already  indicated  (page  319). 

The  deep  palmar  arch  crosses  the  shafts  of  the  second, 
third,  and  fourth  metacarpal  bones  close  to  their  bases  (Fig.  77). 

Each  digital  artery  bifurcates  a  little  more  than  one  quarter 
of  an  inch  above  the  free  edge  of  the  web  of  the  finger. 

Instruments. — A  stout  narrow  scalpel  with  a  blade  about 
1^  inch  long  will  suffice  for  the  oval  methods,  and  a  slender 
bistoury,  with  a  cutting  edge  of  some  9  inches,  is  required  for 
transfixion  operations.  A  fine  keyhole-saw.  Small  retractors. 
Bone-forceps.  An  elevator,  if  the  periosteum  is  to  be  preserved. 
Dissecting  and  artery  forceps.     Scissors,  needles,  etc. 

Position. — The  surgeon  sits  with  the  patient's  hand  before 
him.  The  limb  should  be  in  the  position  of  pronation.  The 
operator  grasps  the  finger  to  be  removed,  keeping  his  hand 
supine.  An  assistant,  placed  opposite  to  the  surgeon,  holds 
the  patient's  hand  in  the  required  position,  and  keeps  the  sound 
digits  out  of  the  way. 

The  following  procedures  will  be  described  : — 

A.  Partial  amputations. 

B.  Disarticulation  of  a  finger  with  its  metacarpal  bone. 

C.  Disarticulation  of  the  thumb  with  its  metacarpal 

bone. 

D.  Amputation   of  several  fingers   with   their  meta- 

carpal bones. 

A.  Partial  Amputations. — As  much  of  the  metacarpus 
should  be  preserved  as  is  possible.  In  such  partial  opera- 
tions the  deep  palmar  arch  is  not  exposed  to  the  risk  of  being 
wounded :  the  attachments  of  certain  tendons  are  preserved, 
the  carpo-metacarpal  synovial  sacs  are  not  opened  up,  and  if 
the  bone  be  divided  beyond  its  centre  the  synovial  sacs  of 
the  flexor  tendons  may  escape  the  knife  in  the  case  of  the 
three  middle  digits. 

The  racket  method  should  be  employed.  The  vertical 
incision  follows  the  median   dorsal  line   of  the  metacarpal, 


AMPUTATION    OF   METAGABPUS.  339 

while  the  oval  cut  traverses  the  web  and  follows  the  transverse 
digito-pahnar  crease. 

The  general  features  of  the  operation  are  the  same  as  in 
the  complete  disarticulations  (vide  infra). 

The  dorsal  incision  should  be  commenced  a  Httle  way 
above  the  point  at  which  it  is  intended  to  divide  the  bone. 

The  bone  should  be  severed  with  a  saw  whenever  possible, 
the  soft  parts  being  protected  by  a  director  during  the  passage 
of  the  instrument.  The  shaft  is  apt  to  be  much  crushed  if 
bone-forceps  are  employed. 

The  second  and  fifth  metacarpals  should  be  divided 
obhquely,  so  that  the  end  of  the  bone  may  not  project  unduly 
upon  the  margin  of  the  hand. 

B.  Disarticulation  of  a  Finger  with  the  corresponding* 
Metacarpal  Bone. — The  racket  incision  is  conveniently  em- 
ployed. The  operation  may  be  illustrated  upon  the  ring 
linger  (Fig.  83,  e).  The  joint  line  having  been  made  out,  the 
queue  of  the  racket  is  commenced  just  above  the  articulation, 
and  is  carried  down  along  the  dorsum  of  the  metacarpal  until 
the  base  of  the  knuckle  is  reached. 

The  incision  here  divides,  and  the  oval  woimd.  followinsr 
the  clefts  between  the  fingers,  crosses  the  web  and  terminates 
transversely  at  the  digito-palmar  crease  in  the  skin. 

The  incision  involves  at  first  the  skin  only,  the  surgeon 
holding  the  finger  and  manipulating  it  as  required  with  his 
left  hand. 

An  assistant  now  takes  charge  of  the  finger  while  the 
surgeon  deepens  the  dorsal  incision  and  divides  the  extensor 
tendons  just  beyond  the  base  of  the  bone. 

The  sides  of  the  shaft  of  the  metacarpal  are  now  bared 
from  one  end  to  the  other,  the  knife  being  kept  very  close  to 
the  bone.  During  this  step  the  surgeon  uses  his  left  finger  to 
assist  m  the  separation  of  the  interossei  from  the  shaft,  the 
assistant  rotating  the  digit  as  required. 

The  knife  is  carried  back  between  the  bases  of  the 
metacarpal  bones  (on  either  side  of  the  bone  to  be  removed), 
so  as  to  divide  the  interosseous  Hgaments ;  the  skin  is  at  the 
same  time  retracted,  so  as  to  expose  the  part.  To  more  con- 
veniently reach  the  articulation,  a  transverse  cut  may  be  made 
at  the  end  of  the  vertical  incision  (Fig.  83,  e). 


3'iU  OFEBATIVE    SURGERY. 

The  operator  now  carries  the  knife  forward  through  the 
tissues  of  the  web  on  either  side  of  the  finger,  and,  the  digit 
being  fully  extended,  the  palmar  incision  is  carried  down  to  the 
tlexor  tendons. 

The  assistant  then  holds  the  finger  in  the  position  of 
the  extremest  extension,  while  the  surgeon  lays  bare  the  under- 
surface  of  the  flexor  tendons,  which  he  ultimately  divides 
opposite  the  neck  of  the  shaft. 

While  the  finger  is  still  extended  to  the  utmost,  the 
operator  exposes  the  palmar  surface  of  the  bone  as  well  as  is 
possible  and  as  far  back  as  is  possible. 

The  Hgaments  of  the  joint  having  been  divided,  the  finger 
is  turned  back  upon  the  dorsum  of  the  hand,  and  the  last 
structures  divided  are  such  resisting  palmar  structures  as  still 
remain,  together  with  the  tendon  of  the  extensor  carpi  radialis 
brevior. 

The  digital  arteries  are  divided  in  the  tissues  of  the  web. 

The  synovial  sheath  of  the  flexor  tendons  should  be  closed 
with  fine  catgut  sutures,  if  possible. 

In  the  case  of  the  index  jvnger  the  vertical  incision  should 
be  carried  along  the  dorsum  of  the  bone  rather  than  along  its 
radial  side,  as  sometimes  advised.  A  transverse  cut  should  be 
made  over  the  trapezoid  at  the  end  of  this  incision. 

In  removing  the  little  finger  with  its  metacarpal  bone,  the 
dorsal  incision  should  be  placed  rather  towards  the  iimer  side 
of  the  shaft  of  the  bone,  and  from  its  extremity  a  short 
transverse  cut  may  be  made  towards  the  ulnar  margin  of  the 
hand  (Fig.  S3,  f). 

In  clearing  the  bone  it  is  convenient  to  have  the  patient's 
elbow  held  upon  the  table  by  an  assistant,  who  at  the  same 
time  flexes  the  forearm  until  it  is  nearly  vertical,  and  well 
abducts  the  finger  to  be  removed. 

The  metacarpal  is  removed  laterally,  and  is  not  turned  up 
upon  the  dorsum  of  the  hand.  During  its  removal  it  is  made 
to  assume  the  position  of  the  extremest  abduction. 

The  operation  by  lateral  internal  flap  cut  by  transfixion  is 
to  be  condemned.  It  has  no  advantages,  and  mvolves  a  scar 
upon  both  the  dorsal  and  paliiiiir  aspects  of  the  hand. 

c.  Disarticulation  of  the  Thumb,  together  with  its  Meta- 
carpal Bone.- -In  this  operation  especial  care  must  be  taken 


AMPUTATION   OF   METACARPUS. 


341 


not  to  wound  the  radial  artery  as  it  passes  close  to  the  base 
of  the  metacarpal  bone  to  reach  the  palm,  and  not  to 
open  the  joint  between  the  metacarpal  of  the  index  and  the 
trapezoid. 

One  of  the  two  following  methods  may  be  employed  : — 

1.  The  Backet  Method. — The  hand  is  to  be  held  in  the 
mid-position  between  pronation  and  supination.  The  -wrist  is 
steadied  by  an  assistant  while  the  surgeon  holds  the  thumb. 

The  dorsal  incision  commences  in  the  tahatiere,  just  above 
the  carpo-metacarpal  joint,  and  on  the  tendon  of  the  extensor 
primi  internodii  pollicis.  It  runs 
along  the  dorsum  of  the  thumb, 
keeping  nearer  to  the  external  than 
the  internal  border  of  the  meta- 
carpal bone. 

The  oval  encircles  the  head  of 
that  bone  and  crosses  the  palmar 
aspect  of  the  digit  on  a  level  with 
the  free  edge  of  the  web  as  dis- 
played when  the  thumb  is  abducted 
(Fig.  84). 

The  incision  at  first  involves  the 
skin  only,  and  the  operator  him- 
self holds  and  manipulates  the 
member  while  the  racket  is  being 
made. 

An  assistant  now  takes  the 
thumb,  and  the  surgeon  proceeds 
to  deepen  the  dorsal  incision  to  the 
bone,  cutting  the  extensores  primi 
and  secundi  as  high  up  as  possible. 

The  dorsal  surface  of  the  bone  and  each  side  of  it  are 
then  bared  of  soft  parts  as  far  as  can  be  effected  from  the 
dorsum. 

The  knife  must  throughout  be  kept  close  to  the  bone. 

The  thumb  is  now  forcibly  abducted.  The  palmar  incision 
is  deepened.  The  muscles  attached  to  the  base  of  the  first 
phalanx  are  divided  close  to  the  sesamoid  bones. 

The  thumb  being  turned  and  rotated  from  side  to  side  by 
the   assistant   as  required,    the  palmar  surface  of  the  meta- 


Fig.  84.  —  DISAETICTXLATION  OF 
THE  THL^MB  WITH  ITS  META- 
CAEPAL  BO>rE  BT  A  RACKET 
INCISION. 


3:12 


OPERATIVE    SURGERY. 


carpal  is  cleared,  the  knife  being  kept  close  to  the  bone.  The 
long  flexor  tendon  may  be  divided  about  the  middle  of  the 
metacarpal  bone. 

The  operator  once  more  takes  hold  of  the  thumb,  and 
wrenching  it  fi'om  side  to  side  as  needed,  effects  the  disarticula- 
tion. 

Probably  the  last  structure  divided  is  the  tendon  of  the 
extensor  ossis  metacarpi  pollicis. 

The  sheath  of  the  flexor  tendon  should  be  closed  if 
possible. 

The  arteria  princeps  pollicis,  or  its  two  collateral  branches, 
will  be  found  divided  on  the  palmar  aspect  of  the  wound  and 

will  require  a  ligature. 
The  vessel  runs  along  the 
palmar  side  of  the  meta- 
carpalbone,  and  bifurcates 
between  the  heads  of  the 
flexor  brevis  and  under 
cover  of  the  long  flexor. 

The  two  dorsal  arteries 
of  the  thumb  are  small 
and  may  not  require  to  be 
secured. 

2.  By  Palmar  Flap. — 
This  operation  may  be 
rapidly  performed,  but  it 
is  decidedly  inferior  to 
the  method  just  described. 
A  considerable  section  of 
the  muscular  tissues  is 
made ;  there  is  greater 
danger  of  wounding  the 
radial  in  the  palm  and  of 
opening  a  carpal  joint. 
The  flap  is  cut  by  trans- 
detailed  by   Sir   William 


Fig.  85. — A,  Disarticulation  of  the  thumb  with 
its  metacarpal  bone  by  palmar  fla]i :  H,  Ampu- 
tation of  the  three  inner  fingers  with  their 
metacarpal  bones. 


thus 


tixion,   and   the  operation  is 
MacCormac  : — 

"  An  assistant  should  grasp  the  finger  while  the  surgeon 
abducts  the  thumb.  The  knife,  introduced  into  the  centre  of  the 
web,  and  passed  towards  the  trapezium,  beneath  the  muscles  of 


AMPUTATION    OF   METACARPUS.  3^.3 

the  thumb,  is  made  to  emerge  at  the  base  of  the  metacarpaJ 
bone,  and  then  by  cutting  outwards  a  rounded  flap  is  formed, 
comprising  the  whole  of  the  tissues  of  the  ball  of  the  thumb 
(Fig.  85,  a).  The  extremities  of  this  flap  are  now  united 
by  a  straight  incision  across  the  dorsal  aspect,  the  thumb 
being  still  held  strongly  abducted,  the  remaining  soft 
tissues  are  divided,  the  joint  opened  on  the  inner  side,  and 
the  disarticulation  completed. 

"  The  flap  may  be  formed  by  introducing  the  knife  at  the 
base  of  the  metacarpal  bone,  and  bringing  it  out  at  the  centre 
of  the  web.     This  is  preferable  on  the  left  side." 

D.  Amputation  of  several  Fingers,  together  with  their 
Metacarpal  Bones. — These  operations  cannot  be  systematised, 
and  the  majority  of  the  procedures  which  figure  in  French 
manuals  must  be  regarded  merely  as  ingenious  dead-house 
operations. 

These  amputations  concern  for  the  most  part  cases  of 
crush  of  the  hand  and  of  frost-bite,  in  which  the  least  amount 
of  tissue  is  sacrificed,  and  in  which  definite  flaps  can  seldom 
be  cut  or  definite  incisions  followed. 

The  following  may  be  briefly  cited  as  methods  which  are 
at  least  theoretically  suitable : — 

1.  Amj^utation  of  the  Two  Inner  Fingers  and  their 
Metaycarpal  Bones. — The  racket  method  may  be  employed. 
The  dorsal  incision  commences  on  the  outer  side  of  the  base 
of  the  fifth  metacarpal,  and  after  following  the  fourth  inter- 
osseous space  but  about  one  inch  it  divides,  one  limb  dividing 
the  web  between  the  middle  and  ring  finger,  and  the  other 
crossing  the  knuckle  of  the  Httle  finger  on  its  inner  side.  The 
Gwo  extremities  of  this  Y-shaped  incision  are  joined  by  a 
transverse  palmar  cut  following  the  palmo-digital  creases. 

2.  Amputaiion  of  the  Three  Inner  Fingers  with  their 
Metat^rpal  Bones. — The  knife  follows  the  lines  shown  in 
Fig.  85,  B.  The  incision  commences  a  little  way  below  the 
base  tf  the  fifth  metacarpal,  runs  downwards  and  outwards 
across  the  palm  below  and  parallel  to  the  main  transverse 
crease.  It  is  then  directed  towards  the  base  of  the  middle 
finger,  and  finally  divides  the  web  to  the  outer  side  of 
that  dgit.  A  similar  incision  is  made  upon  the  dorsum, 
and  in  this  way  equal  dorsal  and  palmar  flaps  are  made. 


344  OPERATIVE    SURGERY. 

3.  Amputation  of  all  the  Fingers  luith  their  Metacarpal 
Bones. — Here  a  short  palmar  flap  may  be  made.  The  lines  of 
the  incisions  are  shown  m  Fig.  82,  K.  The  dorsal  womid  is 
concave  forwards,  the  palmar  womid  convex. 

Some  surgeons  cut  the  palmar  flap  by  transfixion. 

In  any  of  the  operations  named  the  metacarpal  bones  may 
be  sawn  through  near  their  bases,  or  may  be  completely 
removed  by  disarticulation. 

AFTER-TREATMENT   OF   AMPUTATION    OF   THE   FINGERS 
AND   THUMB. 

The  wounds  after  these  operations  as  a  rule  heal  well. 
Portions  of  divided  tendons  may  slough,  and  pus  may  find  its 
way  along  the  sheaths  of  the  tendons  when  those  canals  have 
not  been  closed. 

As  the  skin  of  palmar  flaps  is  usually  thick  and  stiff,  the 
sutures  should  be  well  applied,  and  should  not  be  too  soon 
removed.  Silkworm-gut  sutures  are  well  adapted  for  these 
operations. 

The  hand  should  be  kept  elevated,  and  never  allowed  to 
hang  down,  and  care  must  be  taken  that  too  tight  bandages 
are  not  applied  about  the  wrist. 

In  the  larger  operations,  especially  where  a  palmar  flap  has 
been  cut,  the  hand  should  be  supported  upon  a  splint  in  order 
to  arrest  the  movements  of  the  wrist. 

As  a  rule  no  drainage-tube  is  required ;  but  when  the 
metacarpus  is  concerned,  and  when  the  tissues  of  the  palm 
have  been  lacerated  or  opened  up,  a  tube  may  with  benefit  be 
introduced  and  retained  for  some  twenty-four  or  forty-eight 
hours. 

The  partial  operations  following  upon  crushes  of  the  hand 
must  be  treated  upon  the  same  principles  as  apply  to  com- 
plicated wounds. 


345 


CHAPTER    XV. 

Disarticulation  at  the  Wrist-Joint. 

Opportunities  for  the  performance  of  this  operation  are 
not  common. 

In  cases  of  injury  the  soft  parts  may,  on  the  one  hand, 
be  so  extensively  damaged  as  to  involve  amputation  of  the 
forearm ;  or  the  lesion  may,  on  the  other  hand,  be  so  limited 
as  to  make  it  possible  to  save  the  carpus  or  a  part  of  the 
metacarpus,  with  possibly  a  finger. 

In  cases  of  disease  of  the  carpal  bones  requiring  amputa- 
tion, the  skin  about  the  wrist  is  usually  so  involved  and  so 
penetrated  by  sinuses  that  the  limb  has  to  be  removed 
higher  up. 

As,  moreover,  the  movements  of  pronation  and  supination 
have  probably  been  lost  during  the  progress  of  the  disease,  there 
is  less  reason  for  disarticulation  in  these  cases. 

The  operation  has  been  performed  in  instances  in  which 
excision  of  the  wrist  has  failed. 

Anatomical  Points. — The  styloid  process  of  the  radius  lies 
more  anteriorly  than  does  the  corresponding  process  of  the 
ulna,  and  also  descends  nearly  half  an  inch  lower  down  the 
limb.  Most  of  the  tendons  about  the  wrist  can  be  made 
out  through  the  skin.  The  palmaris  longus  tendon  is  nearly 
opposite  to  the  centre  of  the  wrist  in  front.  A  little  to  its 
outer  side  is  the  larger  but  less  prominent  tendon  of  the  flexor 
carpi  radialis.  In  the  groove  between  these  two  tendons  lies 
the  median  nerve.  Of  the  tendons  at  the  back  of  the  wrist, 
the  most  conspicuous  is  that  of  the  extensor  secundi  internodii 
poUicis.  It  leads  up  to  a  small,  bony  elevation  at  the  back 
of  the  radius,  which  serves  to  indicate  the  centre  of  the 
posterior  surface  of  that  bone,  and  also  the  position  of  the 
interval  between  the  scaphoid  and  semilunar  bones. 

AVhen  the  hand  is  supine,  the  styloid  process  of  the  ulna  is 


346  OPERATIVE    SURGERY. 

exposed  at  the  inner  and  posterior  aspect  of  the  wrist,  to  the 
inner  side  of  the  extensor  carpi  uhiaris.  In  pronation,  how- 
ever, the  process  is  rendered  indistinct,  while  the  head  projects 
prominently  on  the  j)osterior  part  of  the  wrist,  and  is  found  to 
lie  between  the  tendons  of  the  extensor  carpi  ulnaris  and 
the  extensor  minimi  digiti. 

The  tip  of  the  styloid  process  of  the  ulna  forms  the  best 
guide  to  the  wrist-joint.  A  knife  introduced  below  that  point 
of  bone  will  enter  the  articulation.  A  knife  entered  horizon- 
tally just  below  the  tip  of  the  radial  styloid  process  will  hit 
the  scaphoid  bone. 

A  Une  drawn  between  the  two  styloid  processes  slopes 
doAVTiwards  and  outwards,  and  represents  the  extreme  inferior 
limits  of  the  radio-carpal  joint,  while  it  is  at  the  same  time 
nearly  half  an  inch  below  the  summit  of  the  arch  of  that 
articulation. 

Of  the  several  folds  in  the  skin  on  the  front  of  the  wrist,  the 
lowest  is  the  most  distinct  (Fig.  77).  It  is  a  Httle  convex  down- 
wards, crosses  the  neck  of  the  os  magnum  in  the  line  of  the 
third  metacarpal  bone,  and  is  nearly  three-quarters  of  an  inch 
below  the  arch  of  the  wrist-joint.  It  is  about  half  an  inch 
above  the  carpo-metacarpal  joint-line,  and  indicates  very 
fairly  the  upper  border  of  the  anterior  annular  ligament. 

The  skin  on  the  dorsum  of  the  wrist  is  thin,  and  the 
subcutaneous  tissue  is  scanty  and  very  lax.  The  integuments, 
as  a  consequence,  retract  very  considerably  when  divided. 
Farabeuf  states  that  3  cm.  should  be  allowed  for  this 
retraction,  which  he  characterises  as  enormous. 

The  bony  eminences  formed  by  the  tubercle  of  the  scaphoid 
and  the  ridge  of  the  trapezium  on  the  one  side,  and  the  pisiform 
bone  and  the  unciform  process  on  the  other,  should  be  defined. 
The  anterior  annular  lio'ament,  which  is  about  the  size  and 
shape  of  a  postage-stamp,  extends  between  them,  and  bridges 
over  the  hollow  in  which  the  main  tendons  run. 

The  position  and  extent  of  the  synovial  sheaths  for  the 
tlexor  tendons  have  been  already  alluded  to  (page  319). 

Beneath  the  posterior  annular  ligament  are  six  synovial 
ten f Ion-sheaths.  The  sheaths  for  the  extensors  of  the  meta- 
carpal bone  and  first  phalanx  of  the  thumb  and  for  the  radial 
extensors  reach  some  three-quarters  of  an  inch  above  the  radial 


AMPUTATION   AT    THE    WRIST-JOINT.  347 

styloid  process.  The  remaining  sheaths  extend  only  to  the 
upper  margin  of  the  annular  ligament. 

The  position  of  the  palmar  arches  must  be  borne  in  mind. 
The  deep  branch  of  the  ulnar  artery  arises  immediately  below 
the  pisiform  bone.  The  radial,  to  reach  the  back  of  the 
wrist,  crosses  the  external  lateral  ligament  of  the  wrist  upon 
which  it  rests. 

The  wrist-joint  has  a  separate  synovial  sac. 

The  synovial  sheath  of  the  extensor  minimi  digiti  some- 
times communicates  with  the  inferior  radio-ulnar  joint. 

Of  the  ligaments  of  the  wrist  the  anterior  is  the  strongest, 
while  the  posterior  is  the  most  feeble. 

Instruments. — A  narrow  amputating-knife,  with  a  stout 
handle,  and  a  blade  from  three  to  four  inches  in  length.  A 
scalpel.     Dissecting  and  artery  forceps,  scissors,  needles,  etc. 

Position. — The  surgeon  sits  facing  the  patient's  forearm, 
which  is  abducted  horizontally,  and  with  the  hand  pronated. 
An  assistant  stands  facing  the  operator,  and  with  his  back  to 
the  patient's  shoulder.  He  steadies  the  limb,  draws  up  the 
soft  parts,  and  takes  charge  of  the  flaps  as  they  are  formed. 
He  can  also  manipulate  the  hand  if  required.  A  second 
assistant  may  conveniently  attend  to  the  sponging. 

The  following  methods  of  disarticulating  will  be  de- 
scribed : — 

1.  Circular. 

2.  By  elliptical  incision. 

3.  By  long  palmar  flap. 

4.  By  external  flap  (Dubrueil's  operation;. 

1.  The  Circular  Method. — The  circular  incision  is  some 
way  below  the  joint,  and  is  inclmed  a  little  lower  down  upon  the 
radial  than  upon  the  ulnar  side,  in  order  that  the  outer  styloid 
process  may  be  well  cleared. 

The  incision  on  the  inner  side  is  just  above  the  base  of  the 
fifth  metacarpal  bone,  while  on  the  outer  side  it  crosses  the 
first  metacarpal  about  1  cm.  below  the  carpo-metacarpal 
joint  of  the  thumb  (Fig.  82,  l  and  Fig.  86,  a). 

The  surgeon,  holding  the  patient's  hand  in  his  left 
hand,  makes  the  circular  incision,  commencing  it  upon  the 
dorsum,  and  turning  the  hand  from  the  prone  to  the  supine 
position  as  the  knife  travels  round  the  limb. 


348  OPERATIVE   SURGERY. 

The  incision  concerns  at  first  the  skm  and  the  subcuta- 
neous tissues  only,  and  as  it  is  being  made  the  assistant 
draws  up  the  soft  parts  of  the  dorsum. 

The  hand  is  now  allowed  to  drop  into  the  prone 
position,  while  the  operator  dissects  up  the  integuments  of 
the  dorsum  until  the  joint-line  is  reached  and  the  styloid 
processes  are  cleared.  The  left  fingers  are  used  to  assist  in 
this  retraction. 

The  surgeon  once  more  grasps  the  pronated  hand,  and 
flexing  the  wrist  to  the  utmost,  divides  the  left  lateral  liga- 
ment (i.e.,  the  ligament  on  the  operator's  left). 

By  continuing  the  incision  transversely,  all  the  extensor 
tendons  are  severed  opposite  the  line  of  the  articulation, 
the  joint  is  opened,  and  finally  the  right  lateral  ligament  is 
cut. 

Still  flexins:  the  wrist,  and  so  rotating  the  hand  that 
the  border  on  the  surgeon's  right  is  turned  well  forward,  the 
operator  cuts  the  anterior  ligaments  close  to  the  carpus,  and 
clears  the  bony  eminences  at  the  root  of  the  palm.  Unless 
care  be  taken,  the  pisiform  bone  is  very  apt  to  be  left 
behind. 

Little  now  is  left  but  the  mass  of  the  flexor  tendons. 
These  are  dragged  upon  while  the  wrist  is  still  forcibly 
flexed,  and  the  knife  having  been  passed  between  the  carpus 
and  the  tendons  in  question,  the  limb  is  finally  severed  by 
cutting  vigorously  from  within  outwards. 

In  the  final  cut  the  palmar  incision  is  of  course  followed. 
The  wound  is  united  so  as  to  form  a  transverse  cicatrix. 

Haimorrhage. — The  radial  artery  is  divided  in  the  dorsal 
wound  at  its  outer  extremity. 

At  the  inner  angle  of  the  dorsal  wound  the  carpal  branch 
of  the  uhiar  may  be  found  bleeding. 

In  the  palmar  wound  are  divided  the  superficial  and  deep 
portions  of  the  ulnar  artery  on  the  inner  side  and  the  super- 
ficialis  ToLc  on  the  outer. 

2.  The  Elliptical  Method. — So  far  as  the  covering  of  the 
bones  is  concerned,  this  method  is  nearly  equivalent  to  disarti- 
culation by  a  palmar  flap. 

The  position  of  the  patient  and  the  operator  are  the  same. 

The  blade  of  the  knife  should  be  four  inches  in  length. 


AMPUTATION   AT    THE    WRIST-JOINT. 


349 


The  highest  point  of  the  ellipse  is  on  the  dorsum,  a  little 
to  the  inner  side  of  the  middle  lino,  and  half  an  inch  below 
the  line  of  the  wrist-joint. 

The  lowest  point  is  on  the  palm,  in  a  line  with  the  middle 
finger,  and  about  two  inches  below  the  level  of  the  highest 
point. 

In  forming  the  ellipse  between  these  two  points  the  incision 
on  the  ulnar  side  should  pass  between  the  pisiform  bone  and 
the  base  of  the  fifth  meta- 
carpal, while  on  the  radial 
side  it  should  cross  the 
carpo-metacarpal  joint  of 
the  thumb  (Fig.  86,  b). 

The  surgeon,  holding 
the  subject's  hand  in  the 
supine  position,  marks  out 
the  palmar  part  of  the 
ellipse,  commencing  the 
incision  on  the  left  side 
{the  surgeon's  left)  of  the 
hand. 

The  operator  now  pro- 
nates  the  hand  and  marks 
out  the  dorsal  segment 
of  the  ellipse,  the  assistant 
at  the  same  time  drawing 
up  the  integuments  at  the 
back  of  the  hand. 

The  first  incision  con- 
cerns the  skin  and  the  sub- 
cutaneous tissues  only. 

The  remaining  steps  of  the  operation  are  nearly  identical 
with  those  of  the  circular  method. 

The  integuments  on  the  dorsum  are  separated  up  until  the 
styloid  processes  and  the  joint-line  are  cleared. 

The  surgeon,  holding  the  pronated  hand  in  the  position  of 
forced  flexion,  now  divides  in  order  the  left  lateral  ligament, 
the  extensor  tendons  and  posterior  ligament,  and  the  right 
lateral  ligament.  The  tendons  are  divided  immediately 
opposite  to  the  articulation,  which  is  thus  freely  oj^ened, 


Fig.  86. — A,  Palmar  incision  in  the  circular  dis- 
articulation at  the  wrist ;  b  b,  incisions  in  the 
elliptical  disarticulation  at  the  wrist. 


350  OPERATIVE    8UBQEBY. 

The  anterior  ligament  is  now  severed  close  to  the 
carpus. 

The  hand,  still  hanging  down  in  the  position  of  pro- 
nation and  flexion,  is  so  rotated  that  one  or  other  border  is 
turned  forwards  so  as  to  face  the  surgeon.  While  in  this 
position  the  lateral  parts  of  the  ellipse  are  deepened  towards 
the  palm,  and  the  two  bony  eminences  at  the  root  of  the  palm 
are  cleared,  the  knife  being  kept  close  to  the  bone. 

The  instrument  is  held  vertically,  with  its  point  downwards, 
and  is  passed  between  the  mass  of  the  flexor  tendons  and  the 
hollow  of  the  carpus.  With  the  knife  held  in  this  position 
the  "  carpal  canal "  is  cleared  out. 

Nothine  now  remains  but  to  divide  the  flexor  tendons 
and  the  surrounding  soft  parts.  The  tendons  are  dragged 
upon  and  are  cut  obliquely  from  within  outwards,  the  knife 
now  held  horizontally — finally  following  the  existing  cuta- 
neous incision. 

When  the  wound  is  adjusted,  the  cicatrix  appears  as  a 
curved  line  upon  the  dorsum. 

Hcemorrhage. — The  radial  artery  is  cut  in  disarticulating, 
and  is  found  divided  at  the  outer  extremity  of  the  dorsal 
woimd.  It  is  severed  above  the  origin  of  the  branches  to  the 
thumb  and  index  finger. 

In  the  inner  portion  of  the  palmar  flap  the  ulnar  artery  is 
divided  as  it  is  forming  the  commencement  of  the  superficial 
palmar  arch. 

Deeper  in  this  part  of  the  palmar  flap  the  deep  branch  of 
the  ulnar  artery  is  cut. 

In  the  outer  segment  of  the  palmar  flap  the  superficialis 
volse  will  be  found  severed. 

The  deep  palmar  arch  and  the  greater  part  of  the  super 
ficial  arch  are  of  course  removed  with  the  hand. 

3.  By  a  Long  Palmar  Flap. — The  flap  is  U-shaped.  It 
commences  half  an  inch  below  the  radial  styloid  process,  and 
ends  half  an  inch  below  the  tip  of  the  corresponding  process 
of  the  uhia.  The  outer  limb  is  directed  towards  the  gap 
between  the  index  and  middle  fingers,  the  inner  limb  towards 
the  web  between  the  little  and  ring  fingers. 

The  almost  transverse  extremity  of  the  flap  reaches  nearly 
to   the  middle   of  the   metacarpus.      Its  general   outline   is 


AMPUTATION   AT    THE    WRIST-JOINT. 


351 


shoAvii  in  Fig.  87.  The  dorsal  incision  is  carried  straight 
across  the  back  of  the  hmb  from  one  extremity  of  the  palmar 
flap  to  the  other.     It  Avill  therefore  cross  the  carpus. 

A  stout  knife  with  a  blade  some  three  inches  in  length  is 
requii'ed. 

The  operator  grasps  the  patient's  hand  and  holds  it  in  the 
position  of  extension  and  supination. 

Entering  the  knife  half  an  inch  below  the  styloid  process 
to  his  left,  he  carries  it  across  the  palm,  in  the  direction  indic- 
ated,  to    the   correspond- 
ing point    on    the    other 
side  of  the  hand,  and  thus 
marks  out  the  palmar  Hap. 

An  assistant  now  takes 
the  hand  and  retains  it  in 
the  same  position  while 
the  operator  proceeds  to 
dissect  up  the  great  flap. 
This  should  include  all 
the  soft  parts  down  to  the 
flexor  tendons.  A  con- 
siderable portion  of  the 
muscles  of  the  thenar  and 
hypothenar  eminences  will 
consequently  form  a  part 
of  the  flap,  and  the  limb 
of  the  superficial  palmar 
arch  \n\\  be  divided  at  its 
free  end. 

Tlie  flap  should  be  dis- 
sected up  to  the  level  of 

the  radio-carpal  joint,  care  being  taken  to  clear  the  bony 
prominences  in  the  palm  of  the  hand. 

The  surgeon  now  takes  the  hand  and  holds  it  in  the  pro- 
nated  position,  while  the  assistant  draws  up  the  skin  on  the 
back  of  the  limb.  The  dorsal  incision  is  made.  The  inteffu- 
ments  are  dissected  up  to  the  joint-line,  and  the  extensor 
tendons  and  the  ligaments  of  the  wrist  are  divided  precisely 
as  in  the  previous  operation. 

Nothing  now  connects  the  disarticulated  hand  with  the 


Fig.     87.— DISAETICULATION    AT      THE     WEIST 
BT  LONG  PAT.-M-AT?.  FLAP. 


352  OPERATIVE    SURGERY. 

forearm  but  tlie  mass  of  tlie  flexor  tendons  and  tlie  tissues 
about  them. 

These  are  drawn  upon  and  divided  by  a  vigorous  transverse 
cut  made  from  above  do^\^lwards — i.e.,  from  dorsum  to  palm — 
care  being  taken  that  the  palmar  flap  is  held  well  out  of  the 
way  at  the  time. 

The  palmar  flap  should  never  be  cut  by  transfixion.  The 
bony  prommences  in  the  palm  render  such  a  method  difiicult, 
and  an  unduly  scanty  flap  is  apt  to  result. 

Hcfimorrhage. — The  vessels  are  divided  as  in  the  previous 
operation.  The  deep  palmar  arch  and  the  transverse  part  of 
the  superficial  arch  are  removed  with  the  hand. 

4.  Dubrueil's  Operation  by  an  External  Flap.  —  This 
ingenious  method  is  thus  described  by  Chalot  (Chirurgie 
Operatoire,  1886),  who  states  that  he  has  seen  excellent  re- 
sults from  this  operation  in  the  hands  of  Professor  Dubrueil : — 

"  The  incision  is  commenced  on  the  back  of  the  wrist  at  the 
junction  of  the  outer  with  the  middle  third,  and  at  a  point  half 
a  centimetre  below  the  Hne  of  the  wrist-joint.  It  is  thence 
carried  downwards  towards  the  thumb  upon  the  dorsal  aspect 
of  the  Hmb,  and  is  made  to  cross  the  first  metacarpal  bone 
transversely  about  its  middle.  The  incision  now  follows  the 
inner  part  of  the  thenar  eminence,  and  terminates  at  a  point 
diametrically  opposite  to  the  point  at  which  it  was  com- 
menced. This  represents  the  outHne  of  the  external  or 
thenar  flap  (Fig.  S3,  g). 

"  This  flap  is  now  dissected  up  to  its  base,  and  is  made  to 
include  as  much  of  the  thenar  mass  of  muscle  as  is  possible. 

"  The  skin  and  soft  parts  internal  to  the  flap  are  then 
divided  in  a  circular  manner  through  an  incision  on  a  level 
with  the  base  of  the  flap. 

"Disarticulation  having  been  effected,  the  operation  is 
complete. 

"  The  thenar  flap  is  brought  transversely  across  the  face 
of  the  radius  and  ubia,  and  is  there  secured." 

Comment. — Disarticulation  may  also  be  effected  by  a  long 
dorsal  flap.  This  flap  has  its  base  at  the  styloid  processes  and 
its  extremity  opposite  the  centre  of  the  metacarpus.  The 
method  has  little  or  nothing  to  recommend  it.  The  flap  is 
composed    only  of  skin  and    tendons,  is  veiy  retractile,  and 


AMPUTATION   AT    THE    WRIST-JOINT.  353 

very  poorly  supplied  with  blood.  It  affords  a  scanty  covering 
for  the  bones,  and  either  the  integuments  or  the  underlying 
tendons  are  very  apt  to  slough.  If  the  flap  be  composed  of 
skin  only,  its  fate  is  nearly  certain. 

The  amputation  by  equal  palmar  and  dorsal  flaps  corre- 
sponds to  the  circular  method,  with  the  addition  of  a  lateral 
incision  extending  downwards  from  each  styloid  process. 

The  value  of  disarticulation  at  the  wrist  has  been  mucli* 
discussed,  and  by  some  surgeons  it  is  advised  that  in  the 
place  of  this  operation  an  amputation  should  be  performed 
through  the  lower  end  of  the  forearm.  The  objections  urged 
against  the  disarticulation  are  the  following  : — 1.  The  mor- 
tality is  high.  2.  The  cartilage,  if  left  on  the  radius,  is  apt 
to  necrose.  3.  The  resulting  stump  is  ill-adapted  for  the 
adjustment  of  an  artificial  hand. 

1.  The  high  mortality  appears  notably  in  the  records  of 
army  surgeons.  Fletcher,  dealing  with  the  statistics  of  recent 
European  campaigns,  gives  the  mortality  after  amputation  at 
the  wrist  as  42  per  cent.,  while  after  amputation  of  the  forearm 
it  is  21  per  cent.  Legouest  places  the  mortality  of  the  wrist 
amputation  at  46  "7  per  cent. 

These  tigxires  are  only  to  be  explained  by  the  peculiar  cir- 
cumstances of  military  surgery  and  the  probable  frequency 
of  secondar}"  amputations.  In  civil  practice  it  is  rendered 
evident  that  the  mortality  after  disarticulation  of  the  wrist  is 
probably  about  12  per  cent.,  and  that  it  is  decided^  lower 
than  the  mortality  after  amputation  of  the  forearm. 

2.  If  the  cartilao'e  be  sound,  and  the  wound  be  treated 
antisepticall}^,  there  is  no  fear  of  exfoliation. 

3.  This  assertion  does  not  hold  good  at  the  j)resent  day. 
The  stump  after  a  successful  disarticulation  at  the  wrist  is 
better  adapted  for  the  adjustment  of  a  useful  artificial  hand 
than  is  the  stump  low  doAvn  in  the  forearm. 

In  disarticulation  the  movements  of  pronation  and  supi- 
nation are  usually  retained.  In  forearm  amputations  those 
movements  are  lost. 

In  the  matter  of  the  technique  of  the  operation  attention 
may  be  drawn  to  the  following  points : — 

The  disarticulation  is  always  more  readily  effected  from 
the  dorsum.     In  dissecting  up  the  palmar  tissues,  it  is  not 


354  OPERATIVE    SURGERY. 

easy  to  avoid  removing  tlie  pisiform  bone  with  the  soft  parts. 
It  will  often  be  found  more  convenient  to  include  it  in  the 
tissues  of  the  palmar  Hap,  and  to  subsequently  remove  it  by 
dissection. 

In  planning  any  operation,  account  must  be  taken  of  the 
very  gi'eat  retractibility  of  the  dorsal  tissues,  and  of  the 
difficulty  of  properly  covering  the  radial  styloid  process. 

The  lower  ends  of  the  radius  and  ulna  should  not  be 
sawn  off.  If  this  be  done,  the  cancellous  tissue  of  the  bone 
is  exposed,  the  pronation  and  supination  movements  will 
bo  lost,  and  the  attachment  of  an  important  flexor — the 
supinator  longus — is  disturbed. 

Of  the  operations  described,  the  best  procedure  is  im- 
doubtedly  the  elliptical  method.  The  cicatrix  falls  upon  the 
dorsum,  the  bones  are  well  covered,  and  the  free  end  of  the 
stump  is  made  up  of  the  tough  and  well-nourished  tissues  of 
the  palm.     The  styloid  processes  are  well  protected. 

The  operation  by  a  palmar  flap  may  rank  next  in  order  of 
value.  It  has  these  disadvantages  when  compared  with  the 
elliptical  operation  : — The  tissues  of  the  palm  are  more  exten- 
sively encroached  upon  ;  the  flap  is  of  a  somewhat  awkward 
shape,  and,  as  it  includes  the  tougher  parts  of  the  palmar 
integuments,  it  is  a  Httle  unyielding  and  stiff,  and  not  so 
readily  adjusted  as  is  the  smaller  and  less  rigid  flap  of  the 
elliptical  method.  The  flap,  moreover,  contains  more  fatty 
tissue,  and  healing  after  the  operation  is  usually  a  little  slow 

a  cu'cumstance  to  which  the  occasionally  horny  condition  of 

the  skin  may  no  doubt  contribute. 

In  the  pahnar  flap  operation  the  incisions  are  carried 
comparatively  high  up  upon  the  sides  of  the  limb,  and  there 
is  a  little  more  disposition  for  the  styloid  processes  to  be 
exposed  when  the  flap  is  adjusted. 

The  circidar  operation  has  the  merit  of  being  readily  per- 
formed. It  affords,  however,  a  somewhat  scanty  covering  to 
the  bones,  and  the  cicatrix  is  placed  at  the  extremity  of  the 
stump  and  over  the  prominences  of  bone. 

If  the  tissues  of  the  palm  or  of  the  dorsum  have  been 
thickened  by  inflammation,  there  may  be  some  difficulty  in 
dissecting  up  the  covering  of  soft  parts. 

Buhrvunl's  operation  is  ingenious,  and   is  said   to  yield 


AMPUTATION   AT    THE    WRIST-JOINT.  :355 

excellent  results.  A  good  covering  is  provided  for  the  bones, 
and  especially  for  the  radial  styloid  process.  The  flap  is 
substantial,  and  is  well  nourished  with  blood-vessels. 

The  operation  is  well  adapted  for  cases  of  injury  or  dis- 
ease, where  the  palmar  and  dorsal  tissues  are  so  damaged 
as  to  render  any  of  the  three  first-named  procedures  in- 
admissible. 

After-treatment  of  Disarticulation  of  the  Wrist. — The 
rigidity  and  thickness  of  the  palmar  tissues  render  it  neces- 
sary that  in  the  elliptical  or  palmar  flap  operation  the  sutures 
should  be  very  securely  applied,  and  should  not  be  too  early 
removed.  They  should  take  a  hold  of  the  entire  thickness  of 
the  palmar  tissues. 

In  all  instances  the  stump  should  be  placed  upon  a  short 
and  light  palmar  splint.  In  the  case  of  the  tw^o  operations 
just  named  the  splint  serves  to  support  the  palmar  flap,  and 
in  all  disarticulations  at  this  joint  it  serves  to  prevent  pro- 
nation and  supination  movements. 

The  possibility  of  the  sloughing  of  tendons,  or  of  an 
accumulation  of  pus  in  the  remains  of  the  sjmovial  sacs  for 
the  flexor  tendons,  must  be  borne  in  mind. 

A  drainage-tube  should  be  inserted,  and  retained  for 
thirty-six  or  forty-eight  hours. 


X  2 


356 


CHAPTEE    XVI. 

Amputation  of  the  Forearm. 

A  VERY  large  number  of  ditierent  operations  has  been 
•described  under  this  heading,  and  there  is  probably  no  known 
method  of  cutti  ig  flaps  that  has  not  been  recommended  as 
especially  suitable  to  ainputation  of  the  forearm. 

The  fact  that  the  liinb  undergoes  a  considerable  change  m 
its  configuration  and  physical  characters  between  the  elbow 
and  the  wrist  has  no  doubt  excused  the  multiplicity  of 
methods. 

In  the  account  which  follows,  two  operations  will  be 
described,  the  first  being  that  which  appears  best  adapted  for 
the  lower  third  of  the  limb,  the  second  one  well  suited  for  the 
upper  two-thirds. 

Anatomical  Points. — At  its  upper  half,  and  especially  in 
its  upper  third,  the  limb  is  much  wider  in  its  transverse  than 
in  its  antero-posterior  diameter.  A  horizontal  section  through 
this  part  will  show  a  cut  surface  which  is  somewhat  oval  in 
outline,  and  is  at  the  same  time  flattened  in  front  and  more 
convex  behind.  This  outline  is  best  seen  in  muscular  sub- 
jects, and  depends  chiefly  ujDon  the  development  of  the  lateral 
masses  of  muscle  which  descend  from  the  condyles. 

In  the  non-muscular,  the  limb,  even  in  its  highest  parts, 
tends  to  assume  a  rounded  rather  than  an  oval  outline. 

The  ulna  is  subcutaneous  throughout  its  entu'e  extent. 
The  upper  half  of  the  radius  is  deeply  placed,  while  the  lower 
half  is  superficial 

Transver.se  sections  of  the  limb  at  various  levels  show  that 
the  radius  and  ulna  are  in  aU  parts  nearer  to  the  posterior 
than  the  anterior  aspect  of  the  extremity.  This  relation  is 
the  more  marked  the  higher  up  the  section.  The  two  bones 
are  nearest  to  the  centre  of  the  limb  about  the  lower  end  of 
the  middle  third 


AMPUTATION   OF   FOBEATiM.  357 

In  antero-posterior  flaps  cut  by  traiistixion,  the  anterior 
flap  will  consequently  be  ahvays  the  more  substantial. 

At  the  upper  part  of  the  forearm  the  muscles  are  found 
mainly  at  the  sides  and  in  front.  The  lower  the  section 
proceeds  down  the  limb,  the  less  will  the  bones  be  covered  at 
the  sides,  and  the  more  equally  will  the  soft  parts  be  found 
distributed  along  the  anterior  and  ])osterior  aspects  of  the 
limb.  Thus  it  follows  that  the  circular  method  is  best 
adapted  for  the  lower  third  of  the  fore-arm,  and  the  flap 
method  for  the  upper  two-thirds.  It  wiU  be  obvious  also 
that  if  antero-posterior  flaps  be  cut  of  equal  width,  the 
bones  will  have  a  greater  disposition  to  protrude  in  the 
lateral  incisions,  in  the  lower  part  of  the  limb  than  in  the 
upper. 

It  will  be  noticed  that  where  one  bone  is  the  most  sub- 
stantial the  other  is  the  most  slender,  as  near  the  elboAv  and 
wi'ist ;  and  that  it  is  about  the  centre  of  the  limb  that  the 
two  are  most  nearly  of  equal  strength. 

The  interosseous  space  is  narrowest  in  full  pronation  and 
widest  in  supination.  It  is  only  in  the  mid-position  that  the 
bones  are  parallel  to  one  another. 

There  is  a  singular  absence  of  large  blood-vessels  and 
nerves  along  the  posterior  aspect  of  the  forearm. 

The  three  chief  pronator  muscles  are  the  pronator  teres, 
pronator  quadratus,  and  flexor  carpi  radialis. 

The  three  chief  supinators  are  the  supinator  longus, 
supinator  brevis,  and  the  biceps.  If,  therefore,  the  bones — 
in  an  amputation — be  divided  above  the  insertion  of  the 
pronator  teres,  the  radius  will  become  supinated,  and  further 
rotation  movements  will  be  lost. 

The  brachial  artery  divides  opposite  to  the  neck  of  the 
radius,  and  the  ulnar  gives  off  the  interosseous  trunk  one  inch 
below  this  point. 

Instruments. — An  amputating-knife,  with  a  blade  four  to 
five  inches  in  length.  A  stout  scalpel  An  amputating-saw. 
Retractors  (the  linen  retractor  used  to  protect  the  soft  parts 
during  the  sawing  of  the  bones  ma}'  have  three  "  tails," 
the  middle  and  narrowest  slip  being  passed  through  the 
interosseous  space).  Pressure,  artery,  and  dissecting  forceps. 
Scissors,  needles,  etc. 


358  OPERATIVE    SUBGEBY. 

Position. — The  arm  is  abducted,  and  the  surgeon  stands 
to  the  right  of  the  Umb  in  all  cases — i.e.,  to  the  outer  side  of 
the  right  forearm  and  the  inner  side  of  the  left. 

One  assistant — to  the  operator's  left — steadies  the  upper 
arm  and  retracts  the  Haps,  etc.  The  other — to  the  operator's 
right — manipulates  the  forearm  and  hand,  and  attends  to  the 
sponging,  etc. 

The  following  operations  are  described : — 

1.  Circular  method. 

2.  Equal  anterior  and  posterior  flaps. 

3.  Methods  less  fi-equently  employed. 

1.  The  Circular  Method  {through  the  lower  third). — The 
position  'of  the  incision  is  estimated  in  the  usual  way 
(page  271).  The  cu'cular  cut  in  the  skin  will  be  placed  at  a 
distance  below  the  future  saw-line,  equal  to  the  antero- 
posterior diameter  of  the  limb  at  that  line. 

The  patient's  limb  is  held  in  the  supine  position. 

The  surgeon,  passing  his  hand  beneath  the  patient's  fore- 
arm, commences  the  incision  on  that  border  of  the  Hmb 
which  is  the  nearer  to  him,  and  uses  the  heel  of  the  knife 
for  the  purpose. 

The  knife  is  now  dra^n  from  heel  to  point  across  first  the 
flexor  and  then  the  extensor  asjject  of  the  limb,  until  it 
reaches  the  point  at  which  the  incision  was  commenced. 

During  this  manoeuvre  the  operator  grasps  the  forearm 
above  the  incision  with  his  left  hand. 

A  cuff  of  skin  is  now  dissected  up,  and  turned  back  as 
shown  in  Fig.  75,  and  this  retraction  of  soft  parts  should  be 
continued  until  the  level  of  the  future  saw-line  is  reached. 

Throughout,  the  limb  is  kept  with  the  hand  supine,  but 
the  elbow  should  be  flexed  so  as  to  render  the  forearm 
vertical  while  the  posterior  yjart  of  the  raanchette  is  being 
dissected  up. 

The  forearm  being  extended,  with  the  hand  supine,  the 
soft  parts  on  the  flexor  side  of  the  limb  are  transfixed  by 
the  knife,  which  is  so  passed  transversely  across  the  forearm 
that  its  point  is  made  to  enter  and  emerge  at  the  level  of  the 
retracted  skin.  The  knife  should  follow  the  curve  of  the 
bones,  so  as  to  take  up  as  much  of  the  tissues  on  the  front  of 
the  limb  as  possible.     It  is  now  made  to  cut  its  way  abruptly 


AMPUTATION   OF  FORE  ABM.  359 

out,  so  that  the  muscles  and  tendons  shall  be  divided  trans- 
versely a  little  below  the  future  saw-line. 

The  soft  parts  on  the  extensor  side  of  the  limb  are  trans- 
fixed and  divided  in  precisely  the  same  way,  the  limb  being- 
still  kept  in  the  same  position  during  the  process. 

While  the  flexor  tissues  are  being  cut,  the  hand  is  kept 
a  little  extended ;  and  while  the  tissues  on  the  extensor  side 
of  the  Hmb  are  being  cut,  the  hand  is  a  little  flexed. 

The  soft  parts  might  be  divided — as  is  usual — by  a  cir- 
cular sweep  with  the  knife  at  the  level  of  the  retracted  skin  ; 
but  as  the  structures  to  be  severed  are  for  the  most  part 
tendons,  they  are  much  more  easily  and  more  cleanly  divided 
by  cutting  from  within  outwards,  as  advised. 

With  a  scalpel  any  remaining  soft  parts  are  now  sepa- 
rated from  the  bones  until  the  saw-line  is  well  exposed, 
and  at  this  level  the  interosseous  membrane  is  divided  trans- 
versely. 

The  retractor  having  been  applied,  the  bones  are  sawn 
through.  In  dividing  the  bones  it  is  convenient  to  have 
the  hand  placed  in  the  mid-position  between  pronation  and 
supination,  and  to  saw  the  radius  first  and  then  the  uhia. 

Many  operators  keep  the  hand  supine,  and  endeavour  to 
divide  the  two  bones  evenly  and  at  the  same  time. 

HcBTiiorrliage. — On  the  face  of  the  flexor  part  of  the  wound 
are  found  divided  the  radial  and  ulnar  arteries.  The  former, 
no  longer  accompanied  by  the  radial  nerve,  hes  close  to  the 
radius  and  to  the  inner  side  of  the  conspicuous  tendon  of 
the  supinator  longus  muscle. 

The  ulnar  artery  will  be  found  lying  on  the  flexor  profimdus 
digitorum  and  under  cover  of  the  flexor  carpi  ulnaris.  The 
nerve  is  to  its  inner  side.  Behind  the  interosseous  space,  and 
between  the  superficial  and  deep  muscles,  the  posterior 
interosseous  artery  may  be  found  bleeding,  and  in  fi-ont  of  that 
membrane  the  anterior  interosseous  and  possibly  the  median. 

2.  By  Equal  Antero-posterior  Flaps  {through  the  ujyper 
two-thirds). — The  base  of  each  flap  should  be  equal  to  half  the 
circumference  of  the  limb  at  the  level  of  the  saw-hne. 

The  length  of  each  flap  should  be  equivalent  also  to  half 
the  circumference  after  the  usual  allowance  has  been  made  for 
retraction.     Thus,  to  take  the  measurements  recommended  by 


360  OPERATIVE    SURGERY. 

Faraheuf,  if  tlie  circumference  of  the  limb  in  pronation  be 
80  m.m.,  each  flap  should,  after  retraction,  measure  40  m.m. ; 
and  to  allow  for  such  retraction  its  lens'th,  as  marked  out 
upon  the  skin,  should  be  (iO  m.m. 

The  flaps  are  U-shaped,  and  the  lateral  incisions  correspond 
to  the  lateral  margins  of  the  limb.  The  anterior  flap  ^nll 
contain  the  supinator  longus  and  the  flexor  muscles.  The 
posterior  flap  will  contain  the  extensors.  In  the  radial 
incision  the  vertical  cut  wtlU  involve  the  two  extensors  of  the 
radial  side  of  the  carpus.  In  the  lateral  ulnar  wound  the 
flexor  profundus  and  the  flexor  carpi  ulnaris  are  found  to  be 
marked  by  the  vertical  incision. 

The  hand  having  been  supinated,  the  anterior  flap  is 
marked  out  by  a  skin-cut.  In  the  case  of  the  right  limb  the 
Icnife  is  entered  at  the  commencement  of  the  ulnar  incision,  is 
carried  do\\Ti  along  the  uhiar  border,  and  is  then  made  to 
sweep  transversely  across  the  flexor  surface  of  the  limb.  The 
knife  being  withdrawn,  its  point  is  entered  at  the  upper  end  of 
the  radial  incision,  and  is  carried  down  along  the  radial  border 
of  the  forearm  to  meet  the  first  incision.  The  flap  is  marked 
out  therefore  by  two  cuts,  and  the  incision  is  commenced  on 
the  side  more  remote  from  the  surgeon.  In  the  left  hmb  the 
knife  is  first  entered  upon  the  radial  border. 

The  elbow  being  now  flexed  so  that  the  forearm  is  vertical 
(the  hand  being  still  sujDine),  the  posterior  flap  is  marked  out 
in  the  integuments  only. 

The  skin  thus  fashioned  for  the  future  flaps  is  allowed  to 
retract. 

The  forearm  is  now  again  held  horizontally,  with  the 
elbow  a  little  flexed  and  the  hand  still  supine. 

The  operator  lifts  up  the  tissues  on  the  front  of  the  limb 
with  the  fingers  of  the  left  hand,  and  proceeds  to  transfix. 

The  knife  is  entered  at  the  angle  of  the  wound  nearest  to 
the  surgeon,  and  is  made  to  follow  as  accurately  as  possible  the 
curves  of  the  bones  and  the  interosseous  membrane.  Its  pomt 
should  just  graze  the  bones  as  it  moves  across  the  limb. 

While  the  assistant  extends  the  hand,  the  surgeon  cuts  a 
muscular  flap  from  within  outwards,  bringing  the  knife  out 
sliarply  just  at  the  level  of  the  retracted  skin. 

The  posterior  flap  is  cut  by  transfixion  in  the  same  way, 


AMPUTATION    OF   FOREARM.  361 

the  limb  being  held  in  the  same  posture.  It  is  dilHcult  to 
insinuate  the  knife  behind  the  ulna,  and  its  movements  in  that 
position  must  be  assisted  with  the  left  fingers. 

While  the  muscular  tissue  is  being  divided  the  assistant 
flexes  the  hand. 

The  two  flaps  are  now  drawn  up  to  the  level  of  the 
saw-line,  and  the  remaining  soft  parts  are  divided  at  that  level 
to  fully  clear  the  bones. 

This  is  effected  by  what  the  French  surgeons  call  the 
"  incision  en  8  de  chifre  "  (Fig.  88).  The  knife  is  made  to  so 
pass  across  the  front  and  back 

of  the  limb  as  to  follow  the    lv  ^f 

outlines  of  the  bones  and  to 
well  sever  the  interosseous 
membrane.  The  hand  is 
kejDt  supine,  and  both  the  an- 
terior and  posterior  incisions 
are  inade  from  left  to  right, 
and  both  are  commenced  by    Fig.  88.— the  "rNcisioNENSDECHiFFRE." 

the   heel    of     the    knife    and  The  black  and  white  airows  mark  the 

course  oi  the  kniie. 

completed  by  its  point. 

The  threefold  retractor  having  been  applied,  the  bones  are 
sawn  in  the  manner  already  described. 

Some  surgeons  advise  that  the  median,  ulnar,  and  radial 
nerves  should  be  resected  from  the  anterior  flap. 

Hcemorrhage. — The  radial  artery  will  run  the  whole  length 
of  the  anterior  flaj?,  and  be  cut  near  its  outer  border  on  the 
inner  side  of  the  supinator  longus.  The  radial  nerve  accom- 
panies it.  The  ulnar  artery  will  be  cut  shorter,  will  be  in  front 
of  the  bone  and  between  the  flexor  sublimis  and  flexor 
profimdus  digitorum.  The  anterior  interosseous  vessels  will 
be  divided  immediately  in  front  of  the  interosseous  mem- 
brane. The  posterior  interosseous  artery  will  be  cut  long,  and 
will  be  found  between  the  superficial  and  deep  muscles. 

The  more  conspicuous  nerves  form  good  guides  to  the 
divided  vessels. 

3.  Other  Methods. — 1.  By  Long  Anterior  Flap. — This  flap 
will  measure  in  an  adult's  forearm  some  four  and  a  half  inches 
in  length.  The  posterior  flap  is  one  half  the  length  of  the 
anterior.     They  may  be  cut  in  the  manner  just  described. 


362  OPERATIVE    SUBGEBT. 

2.  By  Long  Posterior  Flap. — This  consists  in  the  apphcation 
of  Teale's  method  to  the  forearm,  and  has  been  adopted  for 
amputations  above  the  wrist.  In  practising  the  operation,  care 
must  be  taken  to  mark  out  the  flaps  by  measurement  before 
attempting  to  cut  them,  as  otherwise,  from  the  conical  shape 
of  the  Hmb,  the  long  flap  will  be  apt  to  be  made  too  narrow  at 
its  distal  extremity. 

If  the  posterior  flap  be  carried  below  the  wrist-joint,  its 
lower  part  must  consist  of  skin  only,  as  it  is  scarcely  possible  to 
extricate  the  tendons  from  the  bony  grooves  behind  the  radius. 

As  this  flap  is  large,  and  is  composed  only  of  tendons  and 
of  very  thin  and  retractile  skin,  and  inasmuch  as  it  contains 
no  blood-vessels  of  any  magnitude,  it  is  apt  to  shrink  con- 
siderably, to  slough,  and  to  form  in  any  case  a  scanty  covering 
for  the  bones. 

The  operation  has  little  therefore  to  recommend  it. 

3.  By  Skin-flaps  with  Circular  Division  of  Muscles. — Mr, 
Jacobson  is  of  opinion  ("Operations  of  Surgery,"  page  49) 
that  no  method,  on  the  whole,  answers  so  well  as  this. 

The  posterior  skin-flap  is  about  three  inches  in  length,  the 
anterior  two  inches.  The  muscles  are  divided  by  a  circular 
sweep  at  the  base  of  the  flaps. 

Comment. — The  circular  method  certainly  is  weU  adapted 
for  the  lower  third  of  the  limb,  and  is  no  doubt  the  best 
amputation  in  that  situation.  The  soft  parts  here  being  com- 
posed mainly  of  integument  and  tendons,  sound  flaps  cannot 
well  be  cut. 

It  has  been  urged  against  the  circular  operation  in  this 
place  that  there  is  a  tendency  for  the  cicatrix  to  adhere  to  the 
bone.  If  the  bones  be  well  covered,  and  the  heahng  be  by 
first  intention,  this  objection  can  have  little  weight.  Such 
adhesion  could  be  avoided,  however,  by  replacing  the  circular 
amputation  by  the  method  last  described,  i.e.,  amputation  by 
unequal  antero-posterior  skin  flaps  with  a  circular  division  of 
muscles. 

In  the  upper  two-thirds  of  the  hmb  the  circular  method  is 
not  admissilile  unless  it  be  in  wasted  subjects.  Under  normal 
conditions,  the  outline  of  the  limb,  the  great  mass  of  muscle, 
and  its  intimate  adhesion  to  the  bones,  are  objections  to  this 
operation. 


363 


CHAPTER    XYII. 

Disarticulation  at  the  Elbow-Joint. 

This  operation  is  not  frequently  performed,  and  has  been 
condemned  by  many  as  an  unsound  surgical  proceeding. 

Messrs.  Smitli  and  Walsham  ("  Operative  Surgery,"  2nd 
edition,  1876)  give  no  description  of  the  operation,  on  the 
ground  that  "its  advantages  are  very  questionable  on  the 
living  subject." 

The  amputation — although  it  has  met  with  Uttle  favour 
in  England  —  has  been  extensively  practised  by  French 
surgeons,  by  whom,  moreover,  the  principal  methods  have 
been  devised. 

It  has  been  urged  against  the  operation  that  it  is  more 
difficult  and  less  safe  than  an  amputation  through  the  lower 
part  of  the  arm ;  that  the  soft  parts  have  to  be  divided  very 
low  down  in  order  to  secure  a  covering  for  the  bones  ;  that 
many  vessels — those  forming  the  anastomotic  plexus  about 
the  joint — are  divided  ;  that  the  cartilage  is  apt  to  exfoliate  ; 
and  that  a  stumj)  is  left  which  is  ill-adapted  for  an  artificial 
limb. 

Some  of  these  objections  are  ill-founded,  others  have  dis- 
appeared "vvith  the  advance  of  surgical  progress. 

The  disarticulation,  although  not  really  difficult,  is  certainly 
less  easy  than  an  amputation  through  the  arm,  which  is  one 
of  the  simplest  operations  of  the  kind.  Before  the  develop- 
ment of  antiseptic,  surgery  the  mortality  after  this  disarticula- 
tion was  terrible.  The  statistics  derived  from  the  records  of 
the  Crimean  War  show  the  deaths  to  have  been  over  50  per 
cent.  On  the  other  hand,  the  statistics  of  the  American  War 
produce  a  mortahty  from  the  operation  of  less  than  8  per 
cent. 

It  is  true  that  to  properly  protect  the  bones  a  considerable 
covering  of  soft  parts  is  requh'ed.     At  the  same  time  the  flaps 


364  OPERATIVE    SURGERY. 

may  be  cut   in  so  many  waj^s    tliat  the  methods  employed 
adapt  themselves  to  a  great  variety  of  conditions. 

Several  vessels  are  divided,  but  they  are  small,  and,  as  a 
rule,  not  more  than  three  ligatures  are  required. 

The  cartilage  very  rarely  exfoliates,  provided  that  it 
be  sound,  and  that  the  wound  is  treated  upon  antiseptic 
principles. 

The  stump  is  much  better  adapted  for  the  application  of 
an  artificial  hmb  than  is  that  resulting  from  an  amputation  of 
the  arm.  French  surgeons  speak  very  highly  of  this  opera- 
tion, and  are  emphatic  as  to  its  value. 

Anatomical  Points. — On  the  anterior  aspect  of  the  elbow 
are  seen  three  muscular  elevations.  One,  above  and  in  the 
centre,  corresponds  to  the  biceps  and  its  tendon ;  while  of  the 
two  below  and  at  the  sides,  the  outer  corresponds  to  the 
supinator  longus  and  the  common  extensor  mass,  and  the 
inner  to  the  pronator  teres,  and  the  common  set  of  flexor 
muscles. 

The  biceps  tendon  can  generally  be  very  distinctly  felt. 
The  crease  in  the  skin  laiown  as  the  "  fold  of  the  elbow "  is 
convex  below,  and  is  placed  some  little  way  above  the  line  of 
the  articulation.  Its  lateral  terminations  correspond  to  the 
tips  of  the  two  condylar  eminences. 

The  points  of  these  eminences  are  always  distinct.  The 
inner  condyle  is  the  more  prominent  and  the  less  rounded  of 
the  two.  The  humero-radial  articulation  forms  a  horizontal 
line,  but  the  humero-ulnar  joint  is  oblique,  the  joint-surfaces 
sloping  downwards  and  mwards.  The  external  condyle  is 
three-quarters  of  an  inch  above  the  articular  line,  while  the 
point  of  the  inner  condyle  is  more  than  one  inch  above  that 
part. 

A  line  drav/n  through  the  two  condyles  is  at  right  angles 
with  the  axis  of  the  upper  arm,  but  forms  an  angle  with  the 
axis  of  the  forearm. 

The  joint-hne  of  the  elbow  is  equivalent  only  to  about 
two- thirds  of  the  width  of  the  entire  line  between  the  points 
of  the  two  condyles. 

Between  the  olecranon  and  the  inner  condyle  is  the 
depression  which  lodges  the  ulnar  nerve  and  the  posterior 
ulnar  recurrent  artery. 


AMPUTATION    AT    THE    ELBOW-JOINT.  306 

To  the  outer  side  of  the  olecranon,  and  just  below  tlie 
external  condyle,  there  is  a  depression  in  the  skin,  in  -which 
the  head  of  the  radius  can  be  felt  and  the  inter-articular 
interval  made  out.  The  pit  corresponds  to  the  hollow  between 
the  outer  border  of  the  anconeus  and  the  nuiscular  eminence 
foi-med  by  the  two  radial  extensors  of  the  carpus  and  the 
supinator  longus. 

The  skin  about  the  elbow-joint  is  thin.  In  front  it  has  a 
most  remarkable  disposition  to  retract  after  division,  and  this 
especially  applies  to  the  skin  over  the  radial  border  of  the 
limb.  The  integument  at  the  back  of  the  joint  is  loose,  has 
but  little  tendency  to  retract,  and  is  well  adaiJted  to  bear 
pressure. 

The  brachial  artery  bifurcates  about  a  finger's-breadth 
below  the  centre  of  the  bend  of  the  elbow 

The  details  of  the  plexus  of  anastomosing  arteries  about 
the  joint  should  be  borne  m  mind. 

For  a  hand's-breadth  below  the  olecranon  there  is  almost 
An  entire  absence  of  superficial  veins. 

Of  the  ligaments  of  the  elbow-joint  the  internal  is  the 
most  substantial,  the  external  ranking  next.  The  anterior 
and  posterior  ligaments  are  both  thin. 

In  disarticulating,  it  is  weU  to  remember  that  the  triceps 
is  attached  not  only  to  the  summit  of  the  olecranon,  but  also 
to  its  sides,  and  that  the  brachialis  anticus  is  inserted  into  the 
ulna  beyond  the  coronoid  process. 

In  children  under  ten  the  whole  of  the  upper  part  of  the 
olecranon  is  cartilaginous. 

The  lower  epiphysis  of  the  humerus  joins  the  shaft  at 
seventeen,  with  the  exception  of  the  part  forming  the  internal 
condyle,  which  joins  the  shaft  at  eighteen. 

Instruments. — An  amputating-knife  some  six  to  seven 
inches  in  length  for  transfixion  operation.  A  stout  knife  with 
a  cutting  edge  of  four  to  five  inches,  when  liaps  are  cut  from 
without  inwards,  and  for  disarticulating.  A  scalpel ;  retractors ; 
pressure,  artery,  and  dissecting  forceps  ;  scissors,  needles,  etc. 

Position. — The  arm  is  abducted  to  a  right  angle.  The 
surgeon — except  in  an  instance  below  specified — stands  to 
the  right  of  the  limb  in  all  cases,  i.e.,  to  the  outer  side  of  the 
rigfht  elbow  and  the  inner  side  of  the  left. 


366 


OPERATIVE    SUBGEBY. 


One  assistant,  standing  to  the  operator's  left  and  near  the 
patient's  shoulder,  steadies  the  arm,  retracts  and  supports 
the  flaps,  etc.  The  other,  to  the  surgeon's  right,  holds  and 
manipulates  the  hand  and  forearm. 


The  following  methods  wiU  be  described ; 


The  circular. 
The  elhptical. 
The  large  anterior  flap. 
The  single  external  flap. 
1.  Circular  Method. — In  order  to  prepare  for  the  unequal 
retraction  of  the  skin,  the  incision  must  be  a  httle  oblique. 

Over  the  supinator  longus  it  should  be  about  three  inches 
below  the  joint-line,  and  over  the  posterior  border  of  the  ulna 

one  inch  and  a  half  below  that  level 
(Fig.  89,  a). 

Grasping  the  arm  with  his  left 
hand,  while  an  assistant  holds  the 
forearm,  the  surgeon  makes  the  cir- 
cular incision  with  one  sweep.  He 
begins  with  the  heel  of  the  knife,  and 
upon  the  side  of  the  limb  nearest  tO' 
him,  and  in  order  to  reach  that  side 
he  f)asses  his  own  forearm  beneath 
the  patient's  limb. 

The  incision  involves  the  skin 
only,  and  the  integuments  are  allowed 
to  retract.  When  retraction  has  taken 
place,  the  skin  ceases  to  appear  to  have 
been  divided  obliquely. 

When  the  integuments  have  been 
retracted  to  a  point  about  one  inch 
below  the  line  of  the  articulation,  the 
superficial  muscles  are  divided  by  a 
circular  sweep  at  that  level. 

The  skin  is  further  retracted  until 
the  condyles  are  reached,  and  the  deeply-placed  muscular 
tissue  Avhich  is  still  undivided  is  cut  immediately  over  the 
joint.     An  assistant  draws  up  the  divided  parts. 

The    surgeon    now    grasps    the    forearm    with    his    left 
hand,  and,  keeping  the  elbow  fully  extended,  cuts  the  anterior 


-A 


if'i".  89. -A,  Disarticulation  at 
the  elbow-joint  by  circular 
metliod ;  H,  Disarticulation 
at  the  elbow-joint  by  single 
external  flap. 


AMPUTATION  AT    THE    ELBOW-JOINT.  367 

ligament  and  then  the  lateral  ligaments  ;  or  he  may  directly 
enter  the  joint  from  the  outer  side  by  dividing  the  external 
ligament.  Nothing  now  connects  the  limb  with  the  trunk 
but  the  posterior  ligament  and  the  triceps. 

The  tendon  of  that  muscle  is  the  last  structure  severed. 

The  skin  which  formerly  covered  the  olecranon  now  forms 
a  pouch,  and  an  opening  for  a  drainage-tube  should  be  made 
in  the  centre  of  this  depression. 

The  wound  is  united  so  as  to  form  a  transverse  cicatrix. 

Hcemorrhage. — The  radial  and  uhiar  arteries  will  be  divided 
just  below  their  point  of  origin,  or  the  brachial  will  be  severed 
close  to  the  bifurcation.  In  front  of  the  outer  condyle  the 
superior  profunda,  lying  by  the  musculo-spiral  nerve,  may 
require  a  ligature,  and  the  same  applies  to  the  termination  of 
the  inferior  profunda  behind  the  internal  condyle. 

2.  Elliptical  Methods. — This  operation  may  be  performed 
in  one  of  two  ways  : — 

A.  Ante7'ior  Ellipse  (Farabethf). — The  figure  described  by 
the  incision  is  rather  lozenge-shaped  than  elliptical 

The  highest  point  of  the  ellipse  is  behind,  over  the  promi- 
nence of  the  olecranon.  The  lowest  point  is  on  the  anterior 
surface  of  the  limb,  over  the  eminence  formed  by  the 
supinator  longus,  and  at  a  spot  a  little  above  the  middle 
of  the  forearm  (Fig.  90). 

In  performing  this  operation  the  surgeon  may  conveniently 
stand  to  the  left  of  the  limb  to  be  removed,  i.e.,  to  the  inner 
side  of  the  right  forearm  and  the  outer  side  of  the  left.  The 
elbow  will  be  on  his  right  hand,  the  hand  on  his  left. 

The  elliptical  incision  may  be  made  in  one  sweep  from 
olecranon  to  olecranon. 

Holding  the  wrist  in  his  left  hand,  and  flexing  the  elboAv  a 
little,  the  surgeon  so  rotates  the  limb  as  to  turn  the  farther 
side  of  the  forearm  towards  him.  (This  will  be  the  radial 
margin  on  the  right  limb,  and  the  ulnar  margin  on  the 
left.) 

He  carries  the  incision  downwards  from  the  olecranon  to- 
the  lower  extremity  of  the  ellipse. 

As  the  knife  crosses  the  anterior  aspect  of  the  limb,  the 
forearm  is  kept  extended,  with  the  hand  supine. 

The  elbow  is  once  more  flexed,  and  the  limb  is  now  sa 


368 


OPERATIVE    SURGERY. 


held  as  to  bring  uppermost  tlie  border  of  the  forearm  nearest 
to  the  surgeon. 

The  knife  is  carried  upwards  across  the  border  to  ter- 
minate at  the  point  of  commencement  over  the  olecranon 
(Fig.  90). 

The  incision  involves  the  skin  only. 

An  assistant  now  takes  the  forearm,  while  the  surgeon 
separates  and  retracts  the  integuments  a  little  all  round. 

This  retraction  wiU  shorten  the  anterior  flap  about  one 
inch  and  a  half 

The  elbow  being  a  little  flexed,  and  the  hand  supine, 
the  operator  pinches  up  the  soft  parts  on  the  flexor  aspect 
of  the  bones  with  the  left  hand,  and  then 
transfixes  the  limb  transversely.  The 
knife  should  be  entered  as  near  the  joint 
as  possible,  and  should  pass  close  to  the 
anterior  surfaces  of  the  radius  and  ulna. 

The  muscles  are  cut  obliquely,  and  an 
anterior  flap  is  thus  formed. 

An  assistant  draws  up  this  flajD,  and  the 
surgeon,  keeping  his  loiife  close  to  the 
bones  and  almost  flat,  cuts  upwards  until 
the  anterior  aspect  of  the  joint  is  reached. 

Nothing  now  remains  but  to  dis- 
articulate in  the  manner  already  described, 
and  to  divide  the  triceps  and  any  tissues 
which  have  escaped  division  along  the 
lateral  and  posterior  aspects  of  the  limb. 

A  curved  cicatrix  on  the  posterior 
aspect  of  the  limb  results. 

Hcemorrhage. — In  addition  to  muscular 
branches  divided  with  the  cut  muscles, 
the  radial  and  uhiar  arteries  will  be  found 
severed  near  the  free  end  of  the  anterior 
flap ;  and  on  the  deep  surface  of  that  flap  the  interosseous 
artery,  and  possibly  the  posterior  ulnar  recurrent,  may  require 
li^'-ature.  Bleeding  may  also  occur  from  the  terminations  of 
the  superior  profunda  in  front  of  the  external  condyle,  and  of 
the  inferior  profunda  behind  the  inner  cond3de. 

B.  Posterior  Ellipse   (Soupart).  —  In   this   operation  the 


Fig.  90.  —  DISAETICTT- 
LATION  AT  THE  EL- 
BOW-JOIXT  I5Y  THE 
ANTEEIOB  ELLIPSE 
MliTHOD. 


AMPUTATION   AT    THE    ELBOW-JOINT. 


369 


highest  point  of  the  eUipse  is  in  front  and  the  lowest  point 
behind.  The  flap  is  therefore  taken  from  the  posterior  aspect 
of  the  Hmb  (Fig.  91). 

The  procedure  is  thus  described  by  Ashhurst  ("  Enc3'clo- 
pgedia  of  Surgery,"  vol.  i.,  page  640),  who  considers  the  method 
to  be  "  upon  the  whole  the  best "  : — 

"  The  arm  being  semi-flexed,  the  point  of  the  knife  is 
entered  nearly  an  inch  below  the  internal  condyle  of  the 
humerus,  curved  upwards  over  the  front  of  the  forearm  nearly 
to  the  line  of  the  joint,  and  downwards  again  to  a  point  an 
inch  and  a  half  below  the  external  condyle.  The  arm  being 
then  forcibly  flexed,  the  ellipse  is  completed 
on  the  back  of  the  forearm  by  a  curved  in- 
cision passing  nearly  three  inches  below  the 
tip  of  the  olecranon. 

"  The  cuff  thus  marked  off  is  rapidly  dis- 
sected upwards  as  far  as  necessary,  when  the 
muscles  of  the  front  of  the  forearm  are  cut 
about  half  an  inch  below,  and  the  ulnar 
nerve  as  far  above  the  joint,  and  disarticula- 
tion is  effected  from  the  outer  side 

"  The  brachial  artery  is  divided,  and  other 
vessels  may  be  severed  as  in  the  circular 
operation. 

"  The  wound  is  closed  transversely,  and 
leaves  a  small  curved  cicatrix  in  front  of 
the  bone." 

3.  By  Large  Anterior  Flap. — The  base 
of  the  flap  should  represent  more  than  half 
the  circumference  of  the  limb,  and  should 
be  U-shaped. 

The  anterior  incision  should  commence  three-quarters  of 
an  inch  below  the  line  of  the  joint  on  the  inner  side,  and  one 
inch  and  a  half  below  that  line  on  the  outer  side.  The 
extremity  of  the  flap  (the  curve  of  the  U)  should  reach  some 
three  inches  below  the  articulation. 

The  posterior  incision  is  made  to  connect  directly  the 
extremities  of  the  anterior  incision  (Fig.  92). 

The  position  of  the  operator  has  been  already  indicated 
(page    365).       The   anterior  flap  should  be  marked    out  by 


91. — DISAETICU- 
LATION  AT  THE  EL- 
BOW-JOINT BY  THE 
POSTEKIOK  ELLIPSE 
METHOD. 


370 


OPERATIVE    SURGERY. 


a  skin  incision,  the  limb  beinsf  at  the  time  extended  and 
the  hand  supine,  and  the  knife  should  be  entered  upon  the 
border  of  the  forearm  most  remote  from  the  sursfeon. 

The  muscular  part  of  the  flap  is  cut  by  transfixion  pre- 
cisely as  in  the  anterior  elliptical  method. 

The  flap  is  drawn  up  and  the  posterior  incision  made. 
The  operation  is  completed  as  in  the  disarticulation  by  the 
anterior   ellipse,   and   the  blood-vessels   are 
divided  in  the  same  manner. 

Many  surgeons  cut  a  short  posterior  flap 
about  one-half  or  one-third  the  length  of  the 
anterior  flap. 

4.  By  Single  External  Flap.— This 
operation^ — said  to  have  been  performed  by 
Joubert  in  1848 — is  usually  associated  with 
the  name  of  Guerin. 

The  flap  recommended  by  Guerin  is 
unduly  short.  The  operation  as  modified 
by  Farabeuf  is  here  described. 

The  base  of  the  flaj)  should  correspond  to' 
about  one-third  of  the  circumference  of  the 
limb.  It  is  U-shaped,  and  its  extremity 
reaches  a  point  four  inches  below  the  line 
of  the  articulation. 

The  incision  marking  out  this  flap  com- 
mences on  the  front  of  the  limb,  one  inch 
and  a  half  below  the  joint-line  and  just  to  the  inner  side  of 
the  supinator  longus.  It  descends  vertically  along  the  inner 
border  of  that  muscle,  and  sweeping  over  the  radial  margin  of 
the  forearm,  forms  in  that  position  the  curve  or  tip  of  the  U. 

The  cut  is  now  carried  obliquely  upwards  along  the  poste- 
rior aspect  of  the  Umb  to  end  at  the  level  of  the  articulation, 
and  just  external  to  the  olecranon  (Fig.  89,  b). 

The  inner  incision  is  carried  in  a  circular  manner  around 
the  ulnar  segment  of  the  limb  and  connects  the  extremities  of 
the  external  incision. 

The  position  of  the  surgeon  has  been  already  indicated. 
The  forearm  is  held  extended,  with  the  hand  midway  betAveen 
the  positions  of  pronation  and  supination,  and  with  the  radial 
border  uppermost. 


Fig.  92. — DISARTICU- 
LATION AT  THE 
ELBOW  -  JOINT  BY 
ANTEEIOK   FLAP. 


AMPUTATION   AT    THE    ELBOW- JOINT.  371 

The  external  flap  is  first  marked  out  by  a  skin  incision. 
The  cut  is  commenced  on  the  flexor  side  on  the  right  hmb, 
and  on  the  extensor  side  on  the  left,  and  at  first  concerns  the 
integument  only. 

The  unequal  retraction  of  the  skin  causes  the  anterior 
extremity  of  the  wound  to  reach  the  level  of  the  posterior 
extremity. 

The  skin  having  been  freed,  the  external  flap  is  cut  by 
transfixion,  the  knife  being  passed  close  to  the  radius. 

The  internal  incision  is  now  made,  and  after  the  skin  has 
retracted  the  soft  parts  are  divided  down  to  the  bone  by  a 
vigorous  transverse  cut  at  the  level  of  the  retracted  skin. 

The  outer  flap  is  well  drawn  up,  and  disarticulation  is 
effected  from  the  outer  side,  i.e.,  by  first  dividing  the  external 
lateral  ligament. 

Hcemorrhage. — A  few  muscular  branches  are  divided  in  the 
external  flap.  The  brachial  artery,  just  above  its  bifurcation, 
is  found  divided  on  the  face  of  the  internal  wound. 

Comment. — Several  methods  of  disarticulating  at  the 
elbow-joint  have  been  advised  or  practised  in  addition  to 
those  described.  Among  these  may  be  mentioned  the  amputa- 
tion by  lateral  flaps,  the  external  being  the  larger ;  by  antero- 
posterior flaps,  the  anterior  predominating ;  and  by  a  racket 
incision,  the  queue  of  which  is  over  the  olecranon. 

In  estimating  the  comparative  value  of  the  four  methods 
described,  it  will  be  observed  that  collectively  they  meet  almost 
every  condition  of  limited  or  unequal  lesion  in  which  the 
selection  of  flaps  has  to  be  influenced  by  the  position  of  the 
damaged  parts. 

The  elliptical  vietJiod — and  notably  the  amputation  by  the 
anterior  ellipse — is  on  the  whole  the  best,  provided  of  course 
that  the  tissues  upon  the  flexor  side  of  the  hmb  are  sound. 

Inasmuch  as  in  cases  of  accident  demanding  disarticulation 
the  damage  to  the  soft  parts  is  very  often  upon  the  posterior 
aspect  of  the  joint,  the  operation  is  of  extensive  application. 

The  flap  is  well  supplied  with  blood,  and  provides  an 
excellent  covering  for  the  bone.  Efficient  drainage  is  per- 
mitted, and  there  is  no  skin-pouch  left  over  the  region 
occupied  by  the  olecranon.  The  cicatrix  is  removed  from  the 
extremity  of  the  stump.     A   considerable    demand   is  made 


372  OPERATIVE    SURGERY. 

upon  the  tissues  on  tlie  front  of  the  limb,  and  there   is  an 
extensive  division  of  muscle  substance. 

The  operation  by  the  anterior  flap  has  the  main  advantages 
of  this  method,  and  also  its  disadvantages.  It  provides,  how- 
ever, a  less  efficient  covering  for  the  condyles,  and  the  olecranon 
pouch  is  left.  It  makes,  on  the  other  hand,  a  less  demand 
upon  the  tissues  on  the  front  of  the  limb. 

The  amputation  by  the  posterior  ellipse  provides  a  cover- 
ing for  the  bone  composed  of  skin  accustomed  to  withstand 
pressure.  The  flap  is,  however,  somewhat  scanty,  and  of 
uneven  thickness.  It  is  not  well  supplied  with  blood,  and  the 
conditions  of  the  stump  are  by  no  means  well  adapted  for 
efficient  drainage. 

The  circular  operation  is  a  little  difficult  to  perform.  It 
involves  but  a  comparatively  small  sacrifice  of  parts.  The 
main  artery  and  the  muscles  are  squarely  cut,  and  the  whole 
wound-surface  is  consequently  small.  Excellent  drainage  is 
afforded.  The  end  of  the  humerus  is,  on  the  other  hand, 
somewhat  scantily  covered,  and  the  cicatrix  occupies  the  free 
extremity  of  the  stump. 

The  disarticulation  of  the  single  external  flap  is  well  suited 
for  cases  of  unequal  and  limited  destruction  of  parts,  as  in 
some  instances  of  gunshot  injury.  The  flap,  while  it  provides 
a  good  covering  for  the  bone,  is  not  well  supplied  with  blood, 
and  does  not  encourage  the  most  efficient  drainage.  The  re- 
sulting cicatrices  may  be  found  to  be  inconveniently  placed 
when  an  artificial  forearm  and  hand  are  adjusted. 

The  After-treatment  of  Disarticulations  at  the  Elbow. — 
There  is  nothing  noteworthy  with  regard  to  the  after-treat- 
ment of  these  operation  wounds  except  the  following  : — 

The  stump  should  be  kept  raised  upon  a  supporting 
pillow. 

As  some  of  the  flaps  are  bulky,  and  not  disposed  to  fall  into 
place,  substantial  sutures  are  required,  and  these  should  not  be 
too  early  removed. 

There  is  usually  so  considerable  a  discharge  provided  by 
the  synovial  membrane  that  the  stump  should  be  drained 
with  a  tube.  The  tube  in  an  ordinary  case  need  not  be 
retained  for  longer  than  forty-eight  hours. 


373 


CHAPTER    XVIII. 

Amputation  of  the  Arm. 

The  surgical  rule  that  the  least  possible  amount  of  the  limb 
should  be  removed  by  amputation  applies  conspicuously  to  the 
upjDer  arm. 

Even  the  short  stump  left  when  the  bone  is  sawn  through 
at  the  surgical  neck  is  better  than  that  left  by  disarticulation 
at  the  shoulder-joint.  The  operation  not  only  involves  less 
risk  to  the  patient,  but  affords  a  valuable  point  of  attachment 
for  an  artificial  limb. 

This  amputation  through  the  surgical  neck  will  be 
separately  considered  in  the  next  chapter. 

Anatomical  Points. — In  women,  and  in  those  who  are  fat, 
the  outhne  of  the  arm  is  rounded  and  fairly  regular.  It  is  less 
regular  in  the  muscular,  in  whom  it  may  be  represented  by 
a  cylinder  somewhat  flattened  on  either  side  and  unduly 
prominent  in  front  (biceps  muscle). 

The  outline  of  the  biceps  muscle  is  distinct,  and  on  each 
side  of  it  is  a  groove.  The  inner  of  the  two  grooves  is  by  far 
the  more  conspicuous.  It  runs  from  the  bend  of  the  elbow  to 
the  axilla,  and  indicates  generally  the  position  of  the  basilic 
vein  and  brachial  artery.  The  outer  groove  is  shallow,  and  ends 
above  at  the  insertion  of  the  deltoid  muscle.  So  far  as  it  goes, 
it  marks  the  position  of  the  cephalic  vein. 

The  insertion  of  the  deltoid  can  be  well  made  out,  and  is 
an  important  land-mark.  It  indicates  very  precisely  the 
middle  of  the  shaft  of  the  humerus,  is  on  the  same  level 
with  the  insertion  of  the  coraco-brachialis  muscle,  and  marks 
the  upper  limit  of  the  brachialis  anticus. 

It  corresponds  also  to  the  point  of  entrance  of  the  nutrient 
artery  (which  runs  towards  the  elbow),  and  to  the  level  at 
which  the  musculo-spiral  nerve  and  superior  profimda  artery 
cross  the  back  of  the  bone. 


374  OPERATIVE    SURGERY. 

The  brachial  artery  m  the  upper  two-thirds  of  its  course 
lies  on  the  inner  aspect  of"  the  shaft  of  the  humerus ;  in  the 
lower  thu'd  it  is  placed  directly  in  front  of  the  bone. 

The  superior  profunda  arises  near  the  outlet  of  the  axilla, 
the  inferior  profunda  opposite  the  centre  of  the  humeral  shaft, 
and  the  anastomotica  mao-na  about  two  inches  above  the  bend 
of  the  elbow. 

The  frequenc}^  with  which  variations  in  the  brachial  artery 
are  met  with  should  be  borne  in  mind. 

The  skin  is  thin  and  smooth,  especially  on  the  inner  side 
of  the  Hmb.  It  is  upon  this  asp3ct  of  the  limb  also  that  it  is 
the  most  retractile.  The  skin  over  the  deltoid  is  to  some 
extent  adherent. 

Below  the  middle  of  the  arm  the  biceps  is  the  only  free 
muscle,  the  brachiahs  anticus  and  triceps  being  both  closely 
attached. 

Above  the  middle  of  the  arm  nearly  all  the  divided  muscles 
— viz.,  the  biceps,  the  deltoid,  the  coraco-brachialis,  and  the 
long  head  of  the  triceps — are  more  or  less  free  and  capable  of 
retraction. 

\yhile  therefore  the  circular  operation  is  well  adapted  for 
the  lower  part  of  the  arm,  it  is  ill-suited  for  the  upper 
•ment. 

The  upper  epiphyseal  line  of  the  humerus  is  horizontal, 
and  is  placed  a  little  above  the  surgical  neck.  The  epiphysis 
joins  the  shaft  at  twenty. 

Instruments. — An  amputating-knife  equal  in  length  of 
blade  to  one  and  a  half  times  the  width  of  the  limb  for  trans- 
fixion. A  knife  with  a  still  longer  blade  for  the  circular 
method.  A  stout  knife,  some  four  inches  in  length,  with  which 
skin-flaps  may  be  marked  out  and  muscles  separated  from  the 
bone.  An  amputating-saw.  Some  seven  or  eight  pressure 
forceps.    Artery  and  dissecting  forceps.    Scissors,  retractors,  etc. 

Position. — The  patient  lies  upon  the  back  and  near  to  one 
or  other  edge  of  the  table,  according  to  the  side  of  the  am- 
putation. 

The  limb  is  horizontal,  and  is  abducted  until  it  is  at  right 
angles  to  the  body. 

The  surgeon  stands  to  the  outer  side  of  the  right  arm 
and  the  inner  side  of  the  left. 


AMPUTATION   OF   ARM.  'Mb 

One  assistant  holds  the  hand  and  forearm  and  manipulates 
the  hmb.  A  second  stands  above  the  surgeon  and  attends 
to  the  retraction  of  the  divided  parts.  A  third  assistant 
commands  the  main  artery. 

The  following  two  methods  will  be  described.  The  tirst- 
named  is  considered  to  apply  especially  to  the  lower  half  of 
the  arm,  the  second  to  the  middle  of  the  Hmb : — 

1.  The  circular  method. 

2.  By  antero-posterior  flaps. 

1.  The  Circular  Method  {lower  half  of  the  limb). — Fixing 
the  arm  A\T.th  his  left  hand,  the  surgeon  makes  a  circular  sweep 
through  the  skin.  To  effect  this  he  passes  his  hand  beneath 
the  hmb,  and  bending  his  wrist  over  the  patient's  arm,  he 
commences  his  incision  with  the  heel  of  the  loiife,  upon 
the  surface  of  the  limb  nearest  to  himself  (i.e.,  upon  the 
outer  surface  of  the  right  arm  and  the  inner  surface  of  the 
left). 

The  assistant  holding  the  forearm  so  rotates  the  limb  as  to 
make  the  tissues  meet  the  knife. 

The  cut  can  be  made  to  extend  with  one  sweep  aroimd 
about  three-fourths  of  the  Hmb.  The  circle  is  completed  by 
withdrawing  the  knife,  and  having  entered  it  again  at  the 
point  of  commencement,  the  surgeon  now  cuts  in  the 
opposite  direction — i.e.,  towards  himself — and  so  incises  the 
small  tract  of  skin  yet  undivided  (Fig.  93,  a). 

The  incision  involves  the  skin  only,  and  care  must  be  taken 
that  the  knife  does  not  pass  deep  enough  to  wound  the 
brachial  artery. 

The  integuments  are  now  separated  especially  along  the 
lines  of  the  intermuscular  septa,  and  the  skin  thus  freed  is  well 
and  evenly  retracted  by  the  assistant. 

No  "cuff"  of  skin  should  be  turned  back  In  a  stout  or 
muscular  arm  the  proceeding  is  almost  impossible  unless  a 
lateral  incision  be  made. 

When  the  skin  has  been  sufficiently  dra\vTi  up,  the 
biceps  is  divided  about  a  thumb's-breadth  below  the  edge  of 
the  retracted  skin. 

With  a  circular  sweep  of  the  knife  the  remaining  muscular 
tissue  is  divided  do\\T.i  to  the  bone,  as  close  as  possible  to  the 
edf^e  of  the  divided  inteofuincnt. 


376  OPERATIVE    SUBGEBY. 

This  circular  cut  is  made  in  the  same  manner  as  the  first 
incision  in  the  skin. 

The  assistant  still  fiu'ther  retracts  the  divided  soft  parts, 
until  they  appear  as  a  kind  of  fleshy  cone.  A  second  circular 
incision  is  now  made  at  the  base  of  this  cone,  at  the 
level  of  the  now  fully  retracted  integument.  The  knife  is 
carried  down  to  the  humerus. 

The  bone  is  now  cleared,  the  periosteum  divided,  the 
retractors  are  applied,  and  the  shaft  is  sawn  through. 

Before  applying  the  saw,  it  is  well  to  see  that  the  mus- 
culo-spiral  nerve  is  cleanly  severed.  It  is  apt  to  escape 
division,  as  it  hes  in  the  bony  groove,  and  to  be  mangled  by 
the  saw. 

The  sutures  are  so  applied  that  the  cicatrix  becomes 
vertical  (antero-posterior),  to  ensure  good  drainage. 

Owing  to  the  fact  that  the  skin  upon  the  antero-internal 
aspect  of  the  hmb  retracts  more  than  does  that  upon  the 
remaining  part  of  the  surface  of  the  arm,  it  follows  that  the 
cicatrix  after  an  ordinary  circular  amputation  is  not  terminal, 
but  is  drawn  forwards  and  inwards. 

To  secure  a  terminal  cicatrix,  the  circular  incision  should 
be  not  quite  horizontal,  but  should  incline  lower  do^vn  upon 
the  antero-internal  aspect,  as  shown  in  Fig.  93,  a. 

Hceniorrhage. — The  vessels  are  divided  upon  the  face  of 
the  stump — the  brachial  to  the  inner  side  with  the  median 
nerve ;  the  superior  profunda  upon  the  postero-external  aspect 
of  the  bone  with  the  musculo-spiral  nerve  ;  the  inferior  pro- 
funda to  the  inner  side  of  the  brachial  with  the  ulnar  nerve. 
In  addition  to  these  three  vessels  several  muscular  branches 
will  need  to  be  secured. 

2.  By  Antero-posterior  Flaps  (middle  of  the  limb). — The 
base  of  each  flap  should  be  equal  to  one-half  the  circum- 
ference of  the  limb. 

The  length  of  the  anterior  flap  should  equal  that  of  the 
diameter  of  the  limb.  The  posterior  flap  should  be  half  the 
length  of  the  anterior. 

Both  are  U-shaped,  and  the  incisions  defining  them  are 
commenced  just  below  the  future  saw-line  (Fig.  93,  b). 

These  incisions  are  so  disposed  that  the  brachial  artery 
comes  in  the  posterior  flap,  and  great  care  must  be  taken  that 


AMPUTATION   OF   ABM. 


377 


. 

y      / 

■  V  My 

the  division  between  the  flaps  is  not  just  over  the  vessel,  which 
would  in  such  case  probably  be  split  in  cutting  the  flaps  by 
transfixion. 

An  assistant,  grasping  the  limb  by  the  elbow  and  wrist, 
flexes  the  forearm   and  rotates 
the  extremity  as  required. 

In  marking  out  the  anterior 
flap  the  arm  is  so  rotated  that 
the  flexed  forearm  is  carried 
towards  the  surgeon.  The  in- 
cision is  commenced  on  the  side 
of  the  arm  farthest  from  the 
operator  (i.e.,  on  the  ulnar  side 
of  the  right  arm  and  the  radial 
side  of  the  left). 

The  knife  is  carried  from 
above  downwards.  As  it  sweeps 
across  the  front  of  the  limb  to 
form  the  tip  or  bend  of  the  U 
the  arm  is  held  straight,  and  as 
the  blade  is  carried  upwards  to 
complete  the  other  limb  of  the 
U,  the  arm  is  so  rotated  that 
the  forearm  is  carried  away 
from  the  surgeon. 

The  posterior  flap  is  marked 
out  with  the  knife  in  the  same 
way,  the  arm  being  Hfted  up 
so  that  the  surgeon  can  see  the 
posterior  surface. 

These  incisions  concern  the  skin  only. 

The  skin  having  been  evenly  freed  all  round,  the 
anterior  and  posterior  flaps  are  cut  by  transfixion,  the  edge  of 
the  knife  being  brought  out  at  the  level  of  the  retracted 
skin. 

As  already  said,  care  must  be  taken  not  to  transfix  nor  to 
slit  the  brachial  artery. 

The  bone  having  been  freed  up  to  the  saw-lme,  and 
the  flaps  well  drawn  up,  the  humerus  is  divided,  care  being 
taken  of  the  musculo-spiral  nerve.     (See  page  376.) 


A._- 


Fig.  93.— A,  Circular  (inclined)  ampu- 
tation of  the  arm  ;  b.  Amputation  of 
the  arm  by  anteroposterior  flaps ; 
0,  Amputation  at  the  shoulder-joint 
by  deltoid  flap. 


378 


OPERATIVE    SURGERY. 


The  objections  whicli  have  been  urged  (page  302)  against 
the  cutting  of  the  whole  flap  (muscles  and  skin)  by  transfixion, 
apply  with  especial  force  to  this  part. 

The  flaps  so  cut  are  cut  without  precision,  and  the  muscles 
and  skin  are  divided  at  the  same  level. 

The  rapidity  with  which  the  operation  may  be  performed 
is  its  sole  recommendation. 

ffcemorrhage. — Some  muscular  arteries  are  divided  in  the 
anterior  flap.     In  the  posterior  flap  the  brachial,  the  superior 
profunda,  and  the  inferior  profunda  are 
found  severed. 

Other  Methods. — Among  the  many 
other  methods  of  amputating  the  arm 
may  be  mentioned — 

(a)  Amputation  by  Lateral  Flaps 
(Vermale's  operation).  As  the  inner  flap 
retracts  the  more,  it  is  cut  the  longer  ; 
the  flaps  are  marked  out  by  skin  inci- 
sions and  the  soft  parts  are  then  cut 
by  transfixion. 

There  is  nothing  to  recommend  this 
procedure. 

(b)  Teale's  Amputation  has  been 
performed  in  the  lower  part  of  the 
arm.  The  long  flap  is  j^l^ced  upon 
the  antero-external  aspect  of  the  limb, 
so  that  the  brachial  artery,  with  the 
median  and  ulnar  nerves,  are  found  di- 
vided in  the  posterior  flap  (Fig.  94,  a). 
The  operation  would  be  of  use  in  some 
cases  of  limited  injuiy. 

(c)  Malgaignes  Operation  consists 
in  cutting  a  single  rounded  flap,  usually 
from  the  flexor  surface — a  proceeding 
"  ne  durant  par  une  minute." 

{d)  The  method  known  as  "  Amputation  by  Antero- 
posterior Flaps  with  Circular  Division  of  Muscle"  is  merely  a 
modification  of  the  circular  method.  It  is  little  more  than 
the  turning  back  of  a  divided  skin  "cuff."  The  flaps  are 
about  3  to  3|  inches  long,  and  the  cutting  of  them   renders 


Fig.  94. — A,  Amputation  of 
the  arm  by  Teale's 
method  :  B,  Amputation 
through  the  surgical  neck 
liy  single  external  flap. 


AMPUTATION   OF   ABM.  379 

€asy  the  retraction  of  the  integuments — the  least  simple  part 
of  the  usual  circular  operation. 

The  operation  is  well  suited  for  very  bulky  or  very  muscular 
limbs. 

Comment. — The  circular  operation  is  peculiarly  well 
adapted  for  the  lower  half  of  the  arm,  and  is  undoubted!}^  the 
best  procedure  for  amputation  in  that  situation.  The  method 
is  not  applicable  to  the  upper  half  of  the  limb,  owing  to  the 
freedom  of  the  muscles  and  their  consequent  ready  retrac- 
tion. It  is  here,  therefore,  that  the  flap  operation  proves  so 
serviceable. 

A  terminal  cicatrix  Avould  appear  to  be  the  one  most  likely 
to  be  free  from  pressure  when  an  artificial  limb  has  been 
adjusted. 

After  the  antero-posterior  flap  operation,  the  superior 
retraction  of  the  anterior  flap  tissues  tends  in  time  to  make  the 
cicatrix  terminal 

The  after-treatment  of  these  operations  calls  for  no  especial 
comment. 


880 


CHAPTEE,    XIX. 

Amputation    through  the   Surgical   Neck   of   the 
Humerus. 

In  this  operation — the  amputation  intradeltoidienne  of  the 
French — the  bone  is  sawn  through  between  the  tuberosities  of 
the  humerus  and  the  insertions  of  the  pectorahs  major  and 
latissimus  dorsi. 

The  muscles  left  attached  to  the  bone  in  the  stump  are 
the  subscapularis,  the  supraspinatus,  infraspinatus,  and  teres 
minor. 

The  saw-cut  is  a  little  way  below  the  epiphyseal  line.  It  is 
difficult  to  avoid  opening  the  tubular  prolongation  of  the 
synovial  membrane  of  the  joint  which  accompanies  the  biceps 
tendon  in  its  groove. 

The  bursa  beneath  the  subscapularis  tendon  commonly 
communicates  with  the  joint,  and  may  be  wounded  in  operat- 
ing carelessly. 

The  posterior  circumflex  artery  and  the  circumflex  nerve 
wind  round  the  surgical  neck  of  the  humerus. 

The  advantages  claimed  for  the  operation  are  these : — 

(a)  The  mortality  is  said  to  be  less  than  that  attending 
disarticulation  at  the  shoulder. 

(6)  The  resulting  stump  is  of  considerable  value  in  attaching 
an  artificial  limb,  and  the  scapular  muscles  do  not  waste  to  the 
same  degree  as  occurs  after  amputation  at  the  joint. 

(c)  The  roundness  of  the  shoulder  is  to  a  considerable 
extent  preserved. 

The  disadvantages  are  the  following  : — 

(a)  There  is  much  risk  of  oj^ening  the  shoulder-joint 
through  the  synovial  diverticula. 

(6)  In  young  subjects  the  epiphysis  is  apt  to  produce  bone 
after  the  operation,  and  to  cause  a  conical  stump. 


AMPUTATION   AT   NECK    OF    HUMERUS.  :^1 

(I  once  performed  this  operation  upon  a  lad  of  twelve,  and 
had  on  two  subsequent  occasions  to  remove  portions  of  the 
shaft  of  the  bone,  to  rid  the  patient  of  a  conical  stump  produced 
by  an  active  growth  of  the  epiphysis.  The  stump,  however,  as 
it  appeared  when  the  lad  reached  the  age  of  eighteen  years, 
was  admirable.) 

(c)  The  stump  may  be  rigidly  abducted  by  the  muscles 
attached  to  the  great  tuberosity,  and  become  painful  and  in- 
convenient. 

The  operation  may  be  advised  in  subjects  over  sixteen, 
where  the  case  is  uncomplicated  and  there  is  every  prospect 
of  obtaining  speedy  heahng  without  suppuration. 

One  of  two  methods  may  be  selected : — 

1.  Guthrie's  Operation  by  the  Oval  Method. — The  follow- 
ing is  Guthrie's  description  ("  Commentaries,"  5th  ed.,  1853, 
page  120): — "Amputation  of  the  arm  immediately  below  the 
tuberosities  of  the  humerus  ought  to  be  done  in  the  follow- 
ing manner: — The  arm  being  raised  from  the  side,  and  an 
assistant  having  compressed,  or  being  ready  to  compress,  the 
subclavian  artery,  the  surgeon  commences  his  incision  one  or 
two  fingers'-breadth  beneath  the  acromion  process,  and  carries 
it  to  the  inside  of  the  arm,  below  the  edge  of  the  pectoral 
muscle,  then  under  the  arm  to  the  outside,  where  it  is  to  be 
met  by  another  incision  begun  at  the  same  spot  as  the  first, 
below  the  acromion  process. 

"  The  integuments  thus  divided  are  to  be  retracted,  and  the 
muscular  parts  cut  through,  untd  the  bone  is  cleared  as  high 
as  the  tuberosities.  The  artery  will  be  seen  at  the  under  part, 
and  should  be  pulled  out  by  a  tenaculum  or  forceps,  and  se- 
cured as  soon  as  divided.  The  bone  is  best  sa-\vn,  the  surg-eon 
standing  on  the  outside.  The  nerves  should  be  cut  short,  and 
the  flaps  brought  together  by  sutures. 

"  There  are  few  or  no  other  vessels  to  tie,  and  the  cure 
is  completed  in  the  usual  time,  whilst  the  rotundity  of  the 
shoulder  is  preserved." 

2.  By  Single  External  Flap. — This  operation  is  thus 
described  by  Farabeuf : — 

The  surgeon  marks  out  a  U-shaped  flap,  the  width  of  which 
is  equal  to  one-half  the  circumference  of  the  Hmb,  while  its 
length  is  not  less  than  that  of  the  diameter  of  the  extremity. 


382  OPERATIVE    SURGERY. 

The  base  of  the  flap  should  be  two  fingers'-breadth  below 
the  future  saw-line  (Fig.  94,  b). 

The  internal  incision  is  slightly  curved  downwards. 

The  incisions  at  first  involve  the  skin  only. 

When  the  integuments  have  retracted  evenly,  the  external 
flap  is  cut  by  transfixion.  The  tissues  composing  it  are  picked 
up  with  the  left  hand  as  the  knife  is  passed  across  the  base  of 
the  flap  as  near  the  surgical  neck  as  possible. 

The  structures  on  the  inner  side  of  the  limb,  including  the 
axillary  vessels  and  nerves,  are  now  divided  one  by  one,  with 
the  following  precautions  : — 

Especial  care  should  be  taken  to  preserve  the  tendon  of  the 
great  pectoral  muscle. 

When  the  bone  is  exposed,  the  periosteum  is  divided  below 
the  bicipital  groove,  and  is  carefully  stripped  up  along  that 
groove  by  means  of  an  elevator,  taking  with  it  the  greater 
part  of  the  insertion  of  the  pectoralis  major. 

The  synovial  sheath  of  the  biceps  tendon  should  not  be 
opened,  and  that  tendon,  having  been  picked  up  with  the 
finger,  should  be  divided  moderately  low  down.  The  coraco- 
brachialis  is  divided  with  it. 

The  axillary  vessels  should  be  cautiously  exposed,  and  the 
artery  and  vein  ligatured  before  they  are  cut. 

The  nerve  cords  must  be  severed  high  up  after  they  have 
been  individually  isolated. 

The  tendons  of  the  latissimus  dorsi  and  teres  major  are 
divided  close  to  the  bone,  although  portions  of  their  attached 
fibres  are  separated  with  the  periosteum. 


383 


CHAPTER   XX 

Disarticulation  at  the  Shoulder-Joint. 

Anatomical  Points. — The  roundness  and  prominence  of 
the  point  of  the  shoulder  depend  upon  the  development  of 
the  deltoid  and  the  position  of  the  upper  end  of  the  humerus. 
The  part  of  the  humerus  felt  beneath  the  deltoid  is  not  the 
head,  but  the  tuberosities — the  greater  tuberosity  externally, 
the  lesser  in  front. 

A  considerable  portion  of  the  articular  head  of  the  bone 
can  be  felt  by  the  fingers  placed  high  up  in  the  axilla  when 
the  arm  is  abducted. 

The  head  of  the  humerus  faces  very  much  in  the  direction 
of  the  internal  condyle. 

The  groove  between  the  pectoralis  major  and  deltoid 
muscles  is  usually  to  be  made  out.  In  it  run  the  cephalic 
vein  and  a  large  branch  of  the  acromio-thoracic  artery.  Near 
the  groove  and  a  little  below  the  clavicle  the  coracoid  process 
may  be  felt.  The  process,  however,  does  not  actually  present 
in  the  interval  between  the  two  muscles,  but  is  covered  by 
the  innermost  fibres  of  the  deltoid. 

The  position  of  the  coraco-acromial  ligament  may  be 
defined,  and  a  knife  thrust  through  the  middle  of  it  would 
strike  the  biceps  tendon  and  open  the  shoulder-joint. 

When  the  arm  hangs  at  the  side  with  the  hand  supine, 
the  bicipital  groove  looks  directly  forward. 

In  this  posture  the  head  of  the  bone  lies  entirely  to  the 
outer  side  of  a  line  drawn  vertically  dowuAvards  from  the 
coracoid  process. 

The  skin  over  the  deltoid  is  comparatively  thick  and 
adherent,  and  retracts  little  when  divided.  The  skin  over  the 
pectoral  muscle  and  over  the  inner  surface  of  the  arm  near  the 
axilla  is  finer,  and  retracts  considerably  when  severed. 

The  muscles  about  the  shoulder-joint  and  their  precise 
attachments  should  be  borne  in  mind. 


384  OPERATIVE    SUBGEBY. 

The  capsule  of  the  shoulder-joint  is  veiy  lax.  Its  superior 
part  is  best  exposed  by  carrying  the  elbow  across  the  chest ; 
rotation  of  the  arm  outwards  brings  the  anterior  part  of 
the  capsule  to  the  front,  and  rotation  inwards  the  posterior 
part. 

The  great  subacromial  bursa  intervenes  between  the  cap- 
sule and  the  acromion  process. 

The  main  blood  supply  of  the  deltoid  muscle  is  derived 
from  the  posterior  circumflex  artery. 

This  artery,  with  the  circumflex  nerve,  crosses  the 
humerus  in  a  horizontal  line  which  is  about  a  finger's- 
breadth  above  the  centre  of  the  vertical  axis  of  the  deltoid 
muscle. 

The  dorsalis  scapulae  artery  crosses  the  axillary  border  of 
the  scapula  at  a  point  corresjDonding  to  the  centre  of  the 
vertical  axis  of  the  deltoid  muscle. 

The  acromio-thoracic  artery  emerges  at  the  upper  border 
of  the  pectoralis  minor,  i.e.,  at  a  spot  where  a  line  drawn  from 
the  third  rib  (near  its  cartilage)  to  the  coracoid  process  crosses 
the  line  of  the  axillary  artery. 

Air  ma}^  be  drawn  into  the  axillary  vein  or  into  some  of 
its  larger  tributaries  if  the}^  are  wounded  and  happen  to  be 
exposed  to  the  atmosphere — as  after  sponging — during  an 
inspiration. 

Methods  of  Controlling  Haemorrhage  during  the  Opera- 
tion.— 1.  The  method  of  controlling  bleeding  by  means  of  an 
elastic  band,  which  is  carried  across  the  axilla  and  brought 
well  up  over  the  point  of  the  shoulder,  is  strongly  to  be  con- 
demned as  useless  and  dangerous.  In  such  a  method  the 
axillary  artery  is  compressed  mainly  against  the  humerus.  At 
the  moment  of  the  disarticulation,  the  band  is  apt  to  slip. 
It  is  in  the  way  of  the  operator,  and  cannot  with  any  in- 
genuity be  made  trustworthy. 

2.  The  compression  of  the  subclavian  artery  in  the  neck 
ao-ainst  the  first  rib  is  a  more  certain  mode  of  controlling 
bleeding. 

The  vessel  is  compressed  with  the  fingers  or  with  an 
instrument  shaped  like  the  handle  of  a  door-key.  In  stout 
and  nuiscular  subjects,  and  in  cases  where  the  clavicle  is  lifted 
up,  this  method  is  not  applicable.     Under  such  circumstances 


AMPUTATION   AT    THE    SHOULDER-JOINT.  385 

some  surgeons  have  advised  that  an  incision  should  be  made 
over  the  third  part  of  the  subclavian,  and  the  finger  or  a  com- 
pressor be  introduced  through  the  wound  in  order  that  the 
artery  might  be  more  directly  reached. 

Except  under  special  circumstances,  compression  of  the 
subclavian  is  not  to  be  advised.  Even  with  a  skilled  and 
careful  assistant  the  method  is  not  absolutely  trustworthy. 
The  fingers  are  apt  to  sHp  during  the  movements  of  the  limb 
or  of  the  patient,  and  the  assistant  who  controls  the  artery  is 
somewhat  in  the  way. 

The  methods  that  are  the  most  valuable  are  the  two  next 
described. 

3.  The  main  artery  may  be  compressed  in  the  flap  by  the 
fingers  of  an  assistant,  who  takes  hold  of  the  part  immediately 
before  the  vessel  is  divided. 

This  procedure  is  described  in  the  account  of  Spence's 
operation  (page  388). 

4.  The  artery  may  be  exposed  and  ligatured  before  it  is 
divided  and  early  in  the  course  of  the  operation.  An  account 
of  this  method  is  given  in  the  description  of  Larrey's  disarti- 
culation (page  390). 

Methods  of  Operating. — Sedillot  enumerates  twenty  dif- 
ferent methods  of  disarticulating  at  the  shoulder-joint,  and 
Lisfranc  refers  to  no  less  than  thirty-six  procedures  under  this 
head. 

Farabeuf  gives  illustrations  of  thirty  different  amputations 
at  the  shoulder.  These  illustrations  form  an  excellent 
historical  atlas,  of  which  the  author  modestly  says,  "II  n'est 
pas  complet,  quoique  plus  que  sutiisant." 

Many  of  these  operations  have  been  long  abandoned,  and 
are  merely  curious.  Among  such  may  be  placed  amputa- 
tions by  an  axillary  flap,  as  practised  by  the  elder  Ledran  in 
1715,  and  later  by  Petit  and  Garengeot. 

Others  are  merely  modifications  of  well-recognised  opera- 
tions, as  illustrated  by  the  various  forms  of  external  flap  and 
of  antero-posterior  flaps. 

The  majority  may  be  classified  as  modifications  of  the  oval 
or  racket  operations. 

It  is  desirable  in  any  disarticulation  performed  at  the 
shoulder  that  the  acromion  process  should  be  left,  since  it  helps 
z 


386  OFEBATIVE    SURGERY. 

to  preserve  some  roundness  to  tlie  shoulder  and  to  afford  a 
point  of  suj)port  for  an  artificial  limb. 

It  is  important  also  that  the  axillary  vessels  be  so  ap- 
proached as  to  be  cleanly  and  certainly  cut,  and  that  it  be 
possible  to  secure  them  before  they  are  divided. 

The  glenoid  fossa  should  have  as  good  a  covering  as 
is  possible,  and  the  methods  most  frequently  practised  are 
those  in  which  the  preservation  of  the  whole  or  greater 
part  of  the  deltoid  muscle  is  a  conspicuous  feature. 

The  wound  should  be  vertical  if  efficient  drainage  is  to  be 
secured. 

It  is  well  that  the  axillary  nerves  should  be  divided 
high  up. 

The  following  modes  of  disarticulating  at  the  shoulder 
will  be  described  : — 

1.  The  racket  method. 

A.  Spence's  operation. 

B.  Larrey's  operation, 

2.  The  external  or  deltoid  flap. 

3.  Other  methods. 

Instruments. — A  stout  knife  with  a  blade  from  four  to  fi-v  e 
inches  in  length.  (If  a  transfixion  operation  be  performed,  an 
amputating-knife  with  a  blade  equal  in  length  to  one  diameter 
and  a  half  of  the  limb  will  be  required.)  A  s-alpel.  Ten 
pressure  forceps.  Artery  and  dissecting  forceps.  An  aneurysm 
needle,  metal  retractors,  scissors,  etc. 

Position. — The  patient  lies  close  to  the  edge  of  the  table, 
with  the  shoulders  raised  and  the  head  turned  to  the  opposite 
side.     The  upper  limb  is  carried  a  little  from  the  side. 

The  surgeon  should  stand  to  the  outer  side  of  the  limb  in 
the  case  of  both  the  right  and  the  left  arms.  It  is  often,  how- 
ever, more  convenient  to  stand  to  the  inner  side  of  the  left 
extremity. 

Three  assistants  are  required.  One  stands  above  the 
operator,  by  the  patient's  head,  and,  leaning  over  the  shoulder, 
retracts  the  flaps  and  compresses  the  axillary  vessels  before 
they  are  divided. 

A  second  assistant,  standing  below  the  surgeon,  by  the 
patient's  hip,  holds  the  limb  and  manipulates  it  as  re- 
quired 


AMPUTATION   AT    TEE    8H0ULDEB-J0INT. 


387 


The  third  attends  to  the  sponging.  He  is  placed  either 
facing  the  surgeon  and  upon  the  other  side  of  the  table,  or  by 
the  shoulder. 

1.  The  Racket  Method. — (a)  Spences  Operation. — The 
following  is  Prof.  Spence's  own  account  ("Lectures  on  Surgery," 
vol.  ii.,  page  662) : — 

"  (1)  Supposing  the  right  arm  to  be  the  subject  of  ampu- 
tation. The  arm  being'  slightly  abducted,  and  the  head  of  the 
humerus  rotated  outwards  if  possible,  with  a  broad  strong 
bistoury  I  begin  by  cutting  down  upon  the  head  of  the 
humerus,  immediately  external  to  the  coracoid  process,  and 
carry  the  incision  down,  through  the  clavicular  fibres  of  the 
deltoid  and  pectoralis  major,  till  I  reach  the  humeral  attach- 
ment of  the  latter  muscle,  which  I  divide. 

"  I  then,  with  a  gentle  curve,  carry  the  incision  across 
and  fairly  through  the  lower  fibres  of  the 
deltoid  towards  the  posterior  border  of  the 
axilla,  unless  the  textures  be  much  torn. 
(The  incision  so  far  is  carried  the  whole 
length  directly  down  to  the  bone.) 

"  I  next  mark  out  the  line  of  the  lower 
part  of  the  inner  section  by  carrying  an 
incision  through  the  skin  and  fat  only, 
from  the  point  where  my  straight  incision 
terminated  {i.e.,  at  the  lower  end  of  the 
insertion  of  the  pectoralis  major),  across 
the  inside  of  the  arm,  to  meet  the  in- 
cision at  the  outer  part  (Fig.  95).  This 
ensures  accuracy  in  the  Ime  of  union,  but 
is  not  essential. 

"(2)  If  the  fibres  of  the  deltoid  have 
been  thoroughly  divided  in  the  line  of  incision,  the  flap  so 
marked  out  can  be  easily  separated  (by  the  point  of  the  finger, 
without  further  use  of  the  knife)  from  the  bone  and  joint, 
together  with  the  trunk  of  the  posterior  circumflex,  which 
enters  its  deep  surface,  and  be  drawn  upwards  and  backwards 
so  as  to  expose  the  head  and  tuberosities. 

"(3)    The  tendinous  insertions   of  the   capsular  muscles, 
the  long  head  of  the  biceps  and  the  capsule,  are  next  divided 
by  cutting  directly  on  the  tuberosities  and  head  of  the  bone 
z  2' 


Fig.     95.  —  DISAETICTT- 
LATION         AT  THE 

SIIOUIDEEBT  EACKET 

INCISION.      {Spe)ice's 
operation.) 


388  OPERATIVE    SURGERY. 

(the  humerus  being  rotated  by  the  assistant  as  required). 
The  broad  subscapular  tendon  especially,  being  very  fully 
exposed  by  the  incision,  can  be  much  more  easily  and  com- 
pletely divided  than  in  the  double-flap  method.  By  keeping 
the  large  outer  flap  out  of  the  way  by  a  broad  copper 
spatula  or  the  finger  of  an  assistant,  and  taking  care  to  keep 
the  edge  of  the  Imife  close  to  the  bone,  as  in  excision,  the 
trunk  of  the  posterior  circumflex  is  protected. 

"Disarticulation  is  then  accomplished,  and  the  limb  re- 
moved by  dividing  the  remaining  soft  parts  on  the  axillary 
aspect." 

(4)  This  final  step  of  the  operation  is  effected  as  follows: — 

The  arm,  abducted  and  rotated  out,  is  thrust  upwards  by 
an  assistant  until  the  head  of  the  bone  is  projecting  well 
above  the  glenoid  cavity.  The  surgeon,  taking  hold  of  the 
head  thus  made  prominent,  draws  it  a"way  from  the  trunk, 
while  he  passes  his  knife  behind  it  so  as  to  cut  the  posterior 
part  of  the  capsule  and  the  only  remaining  tissues — those  of 
the  axilla — which  connect  the  arm  to  the  trunk. 

An  assistant  follows  the  knife  with  his  two  thumbs,  while 
he  keeps  the  fingers  of  both  hands  spread  out  over  the 
axillary  integument.  Just  before  the  main  vessels  are  di- 
vided he  firmly  compresses  them,  and  holds  the  flap  until  the 
several  trunks  are  secured. 

All  the  soft  parts  of  the  axillary  aspect  are  divided  with 
one  sweep  of  the  knife,  which  is  made  to  emerge  from  the 
skin  woimd  already  marked  out.  The  operation  is  completed 
by  cutting  the  axillary  nerves  short,  and  by  uniting  the 
wound  so  as  to  form  a  vertical  cicatrix. 

vSpence  pointed  out  that  the  main  vessel  might  be 
secured  by  ligature  early  in  the  operation,  if  thought  welL 
"  By  a  few  touches  of  the  bistoury,"  he  writes,  "  the  vessel  can 
be  exposed,  and  can  then  be  tied  and  divided  between  two 
hgatures,  so  as  to  allow  it  to  retract  before  dividing  the  other 
textures." 

In  disarticulating,  the  capsule  should  be  divided  trans- 
versely by  a  cut  made  upon  the  head  of  the  bone.  The  three 
muscles  attached  to  the  greater  tuberosity  are  cut  while  the 
humerus  is  being  rotated  in,  the  subscapularis  while  it  is 
beintf  rotated  out. 


AMPUTATION   AT    THE    SHOULDEB-JOINT.  38!) 

If  the  humerus  be  fractured,  the  upper  fragments  should 
be  grasped  Avith  hon  forceps  as  soon  as  the  deltoid  Hap  has 
been  dissected  up,  and  manipulated  as  required  during  the 
disarticulation. 

When  the  limb  is  very  muscular,  Spence  advised  that  the 
skin  and  fat  should  be  raised  a  little  from  the  deltoid  alonsf 
the  outer  part  of  the  incision,  and  that  when  a  certain 
amount  of  the  lower  portion  of  the  muscle  had  been  exposed 
its  fibres  should  be  divided  by  a  second  incision.  This  deep 
incision  would  be  a  good  deal  higher  than  the  one  usually 
made,  and  so  an  excess  of  muscular  tissue  in  the  flap  would 
be  avoided. 

HcBTYiorrhage. — The  main  artery  is  divided  between  the 
origins  of  the  posterior  circumflex  artery  and  the  superior 
profunda. 

On  the  edges  of  the  vertical  incision  there  may  be 
bleeding  from  the  humeral  branch  of  the  acromio-thoracic 
artery,  and  in  the  depths  of  that  incision  the  anterior  cir- 
cumflex artery  will  be  divided. 

There  will  be  bleeding  from  muscular  branches  in  the 
deltoid  flap,  and  considerable  haemorrhage  should  the  pos- 
terior circumflex  artery  be  unintentionally  cut. 

(b)  Larreys  Operation. — This  is  the  method  designated 
by  Farabeuf  as  the  best  of  the  many  operations  for  dis- 
articulation at  the  shoulder. 

The  skin  incisions  are  those  given  by  Larrey,  the  mode  of 
dividing  the  muscles  is  ascribed  to  Marcellin  Duval,  and  the 
method  of  securing  the  main  artery  to  Verneuil. 

(1)  The  limb  being  held  a  short  distance  away  from  the  side 
by  an  assistant,  the  surgeon  steadies  the  skin  of  the  shoulder 
with  the  left  hand  while  he  makes  a  vertical  cut,  which 
is  commenced  just  below  and  just  in  front  of  the  prominence 
of  the  acromion,  and  is  continued  down  the  arm  for  four 
inches. 

Along  this  incision  the  knife  is  carried  through  the  fibres 
of  the  deltoid  muscle  to  the  bone.  By  means  of  this  pre- 
liminary wound  the  shoulder-joint  may  be  explored. 

(2)  From  the  centre  of  the  vertical  incision  the  oval  part  of 
the  racket  is  commenced,  and  is  carried  across  the  front  of 
the  arm  to  pass  transversely  over  the  inner  side  of  the  limb 


3yo 


OPERATIVE    SUBGEBY. 


on  a  level  with  tlie  lowest  point  of  the  vertical  incision.  It  is 
finally  continued  up  along  the  postero-external  aspect  of  the 
limb  to  end  where  it  commenced  (Fig.  9G). 

This  oval  cut  at  first  involves  the  integuments  only.  On 
the  right  arm  it  may  be  made  with  one  sweep  of  the  knife, 
commencing  with  the  anterior  segment  of  the  oval  and 
finishing  with  the  posterior. 

On  the  left  extremity  the  two  curved  incisions  marking 
out  the  oval  maj''  be  commenced  at  the  lowest  point,  and  be 
each  made  by  cutting  from  below  upwards. 

(3)  The  anterior  part  of  the  wound  is  now  deepened  by 
cutting  through  the  anterior  segment  of  the  deltoid.     The 

tendon  of  the  great  pectoral  muscle 
is  exposed,  isolated,  and  divided 
close  to  the  bone.  The  coraco- 
brachialis  and  biceps  are  m  the 
next  place  isolated  and  then  di- 
vided. 

To  the  inner  side  of  these  struc- 
tures the  axillar}^  artery  is  exposed, 
and  is  secured  below  the  origin 
of  the  posterior  circumflex.  It 
may  be  secured  between  two  liga- 
tures and  then  divided. 

(4)  Tl  e  ope  rator  now  turns  to 
the  posterior  p  irt  of  the  oval,  and 
divides  the  wh^le  of  the  posterior 
segment  of  the  deltoid,  carrying  the 
knife  back  to  the  under  part  of  the  axilla. 

While  these  deep  incisions  are  being  made  the  arm  is 
rotated  as  required. 

(5)  Disarticulation  is  now  eii'ected  precisely  as  in  the  previous 
operation,  and  the  remaining  axillary  tissues  which  connect 
the  limb  with  the  trunk  are  severed  in  the  same  manner. 

In  this  last  step  of  the  operation  care  should  be  taken 
that  the  knife  cuts  its  way  out  along  the  skin-wound  already 
marked  upon  the  surface,  and  that  the  main  vessel  is  severed 
only  between  the  ligatures. 

Any  hanging  portions  of  capsule  are  removed,  the  nerves 
are  cut  short,  and  the  wound  is  adjusted  vertically. 


Tig.     96.  —  DISARTICULATION     AT 

THE  SHOui.DEE-joiNT.  {Lurrey^ s 
operatio)!.) 


AMPUTATION   AT    TEE    SHOULDER-JOINT.  391 

Hcemorrhage. — The  main  artery  is  divided  as  in  the  pre- 
vious operation.  Some  bleeding  may  occur  from  the  anterior 
circumflex  artery  in  the  region  of  the  bicipital  groove. 

The  posterior  circumflex  artery  is  very  apt  to  be  divided 
in  the  posterior  segment  of  the  oval  incision. 

2.  The  External  or  Deltoid  Flap. — This  method  appears 
to  have  been  extensively  performed  in  England  prior  to 
the  introduction  of  the  disarticulation  through  the  racket 
incision. 

If  the  outer  flap  be  cut  by  transfixion,  the  procedure  has 
the  merit  of  being  very  rapidly  performed. 

The  operation  is  one  of  the  two  methods  of  amputating  at 
the  shoulder-joint  ascribed  to  Dupuytren.  It  is  associated 
also  with  the  names  of  Paroisse  (1800),  Grosbois  (1803),  and 
Charles  Bell  (1808). 

The  base  of  the  flap  extends  from  the  coracoid  process  in 
fi'ont  to  the  spine  of  the  scapula  at  the  root  of  the  acromion 
behind.  It  is  U-shaped,  and  its  extremity  reaches  nearly  to 
the  insertion  of  the  muscle.  If  well  shaped,  the  flap  includes 
practically  the  whole  of  the  deltoid.  At  its  base  it  should  be 
represented  by  the  entire  thicloiess  of  the  muscle,  while  e.t 
its  margins  it  should  be  comparatively  thin. 

The  surgeon  should  always  stand  at  the  outer  side  of  the 
limb,  and  almost  facing  the  patient. 

(1)  The  flap  is  marked  out  by  a  skin-incision.  In  dealing 
with  the  right  shoulder,  the  arm  should  be  carried  well  across 
the  chest  and  the  knife  be  entered  at  the  root  of  the  acro- 
mion. It  is  then  made  to  follow  the  outline  of  the  deltoid, 
and  to  end  at  the  coracoid  process  (Fig.  93,  c). 

As  the  knife  is  carried  up  towards  the  latter  point  the 
arm  is  withdrawn  from  the  chest  and  a  little  abducted. 

It  is  more  convenient  that  the  surgeon  should  manipulate 
the  limb  himself  with  his  left  hand. 

On  the  left  shoulder  the  process  is  reversed.  The  arm  is 
drawn  away  from  the  side  and  the  incision  commences  at  the 
coracoid.  As  it  approaches  the  acromion  the  arm  is  brought 
across  the  chest. 

(2)  The  knife  is  now  carried  deeply  along  the  whole 
length  of  the  incision,  and  the  fla])  containing  the  substance 
of  the  deltoid  muscle  is  raised.     In  cutting  the  flap  the  knife 


392  OPERATIVE    SURGE RY. 

should  be  held  a  little  obliquely,  in  order  that  the  section 
of  the  muscle  may  be  comparatively  thin  at  the  margins  of 
the  flap. 

The  flap  is  drawn  well  upwards  by  an  assistant,  and  the 
outer  surface  of  the  shoulder-joint  is  thereby  exposed. 

(8)  A  transverse  incision,  involving  the  skin  only,  is  now 
made  across  the  inner  side  of  the  arm,  about  two  inches 
below  the  outlet  of  the  axilla.  It  joms  the  great  wound  in 
front  and  behind. 

(4)  Disarticulation  is  finally  effected  in  the  manner  already 
described,  and  the  operation  is  completed  precisely  as  in  Spence's 
method.  That  is  to  say,  that  after  the  disarticulation  the  head 
of  the  bone  is  thrust  upwards  and  outwards,  and  is  grasped 
by  the  surgeon,  who  passes  his  knife  behind  it  so  as  to  cut 
the  very  short  internal  flap.  In  effecting  this  the  knife  at 
first  passes  do^^^lward  close  to  the  bone,  and  divides  the 
pectoralis  major,  latissimus  dorsi  and  teres  major  muscles. 
It  is  then  made  to  cut  its  way  sharply  outwards  through  the 
incision  already  made  in  the  skin. 

In  this,  the  last  movement  of  the  knife,  are  divided  the 
coraco-brachialis,  biceps,  and  triceps,  with  the  axillary  vessels 
and  nerves. 

An  assistant  follows  the  knife  with  his  thumbs,  and  com- 
presses the  great  vessels,  before  they  are  cut,  in  the  manner 
already  detailed. 

Hcemorrhage. — In  the  deltoid  flap  there  will  be  bleeding 
from  muscular  branches  only,  notably  from  such  as  are  fur- 
nished by  the  acromio-thoracic  artery.  The  posterior  cir- 
cumflex artery  will  have  been  cut.  The  axillary  vessels  are 
divided  at  the  free  edge  of  the  inner  flap,  the  artery  being  cut 
below  the  origin  of  the  two  circumflex  vessels.  These  arteries 
will  be  found  severed  in  the  margin  of  the  inner  flap,  and  the 
posterior  of  the  two  will  certainly  require  a  ligature. 

3.  Other  Methods. — The  following  will  be  described : — 

A,  By  antero-postcrior  flaps. 

B.  By  the  circular  method, 
c.  By  the  elliptical  method. 

A.  The  amputation  by  Anterior  and  Posterior  Flaps  is 
usually  ascribed  to  Lisfranc. 

It  was  strongly  advocated  by  Fcrgusson,  who  practised  it. 


AMPUTATION   AT    THE    SEOULBER-JOINT. 


J93 


Although  the  operation  would  probably  not  be  performed  at 
the  present  day,  it  is  worthy  of  note  as  a  brilliant  and  difficult 
procedure. 

It  requires — more  than  does  any  other  disarticulation  at 
this  joint — great  skill  of  hand,  and  certaint}'^  and  rapidity  of 
movement. 

The  description  which  follows  is  in  Fergusson's  own.  words, 
and  applies  to  the  left  limb  : — 

"  The  surgeon,  standing  on  the  patient's  left  side,  should 


Fig.  97. — AMPUTATION  AT  THE  SHOULDER- JOINT  BY  TRANSFIXION.    (From  Fergusson's 
"Practical  Surgery,"  enlarged,  but  drawn  precisely  to  scale.) 


then  lay  hold  of  the  arm  a  little  above  the  elbow,  and  move  it 
from  the  side  and  slightly  backwards,  so  as  to  give  a  view  of 
the  skin  in  the  axilla.  An  amputating-knife — seven  or  eight 
inches  in  length — held  in  the  right  hand,  should  then  be  pushed 
through  the  skin  in  the  armpit,  immediately  in  front  of  the 
tendons  of  the  latissimus  dorsi  and  teres  major  muscles,  and 
carried  upwards  and  obliquely  forwards  until  its  point  protrudes 
a  Httle  in  front  of  the  extremity  of  the  acromion  (Fig.  97). 

"  During  this  movement  a  good  anatomist,  with  a  dextrous 
hand,   may   actually   open   the   capsule   behind,   by  adroitly 


394  OPERATIVE    SURGE  BY. 

touchiug  tlie  tendons  of  tlie  teres  minor  and  infraspinatus. 
....  The  thrust  will  be  greatly  facilitated  by  moving  the 
elbow  outwards,  upwards  and  backwards  ;  indeed,  unless  this 
be  attended  to,  there  is  every  chance  of  the  point  of  the  knife 
appearing  through  the  skin  long  before  it  has  reached  the 
extremity  of  the  acromion.  Keeping  the  arm  in  the  attitude 
last  mentioned,  the  knife  should  be  thrust  up  to  its  heel,  and 
then  carried,  with  a  sawin^  motion,  downwards,  backwards  and 
outwards,  so  as  to  make  a  flap  four  or  five  inches  in  length, 
formed  chiefl}^  of  the  posterior  part  of  the  deltoid  with  the 
tendons  of  the  latissimus  dorsi  and  teres  major  and  the  skm. 

"  This  flap  being  raised  by  an  assistant,  the  point  of  the  knife 
should  be  used  to  open  completely  the  posterior  and  upper 
part  of  the  joint  by  a  thorough  division  of  the  teres  minor, 
infraspinatus,  supraspinatus,  capsule,  and  long  heads  of  the 
biceps  and  triceps.  To  facilitate  these  steps  the  elbow  should 
now  be  carried  in  fi'ont  of  the  chest  and  the  head  of  the  bone 
pushed  backwards. 

"When  the  textures  are  sufiiciently  divided,  the  same  move- 
ment will  cause  the  luxation  of  the  articular  surface.  The 
knife  should  then  be  passed  in  front  of  the  bone  and  carried 
downwards  and  forwards,  to  form  a  flap  about  the  same  length 
as  the  other,  by  dividing  the  subscapular  muscle,  the  re- 
maining portions  of  the  capsule  and  of  the  deltoid,  short 
head  of  the  biceps,  pectoralis  major,  vessels,  nerves  and  skin  of 
the  axilla  and  fore-part  of  the  shoulder. 

"  In  the  last  movements  of  the  knife  the  axillary  artery  must 
be  divided  ;  and  to  restrain  htemorrhage,  an  assistant  at  this 
period  of  the  operation  should  grasp  the  soft  parts  in  the 
axilla." 

On  the  right  Hmb  the  process  is  reversed,  and  the  knife 
having  been  entered  at  the  base  of  the  acromion,  is  brought 
out  at  the  posterior  margin  of  the  axilla. 

This  operation  has  little  to  recommend  it  except  rapidity 
of  execution.  The  flap  is  not  so  good  as  that  formed  out  of 
the  deltoid  alone,  a  very  wide  section  of  the  muscles  is  made, 
and  the  procedure  has  no  advantages  which  can  counter- 
balance the  difficulty  attending  its  performance. 

15.  The  Circular  Method,  as  advised  by  Alanson,  Cornuan, 
and  others,  has  never  been  favourably  received.   Disarticulation 


AMPUTATION   AT    THE    SHOULDER-JOINT.  395 

is  almost  impossible  unless  a  vertical  incision  be  made  to  meet 
the  circular  cut,  and  when  that  has  been  done  the  operation  is 
simply  an  inconvenient  modification  of  the  racket  amputation. 

c.  The  Elliptical  Method  was  employed  by  Marcellin  Duval. 
The  lower  point  of  the  ellipse  was  on  the  inner  side,  and  was 
on  the  level  of  a  point  four  inches  below  the  acromion.  The 
outer  or  upper  point  of  the  ellipse  was  two  and  a  half  inches 
below  that  process. 

The  ojjeration  is  clumsy  and  most  difficult,  and  the  flaps 
are  ill-fitting. 

Comment. — Of  the  three  chief  operations  especially  de- 
scribed at  the  commencement  of  this  chapter,  the  best  are 
those  of  the  racket  incision ;  and  of  the  two  detailed,  the  greater 
value  must  attach  to  Spence's  method. 

The  advantages  claimed  for  the  operation  are  the 
following : — 

1.  The  articulation  is  easily  exposed,  and  an  excision  can 
be  performed  through  the  vertical  cut  should  the  case  on 
examination  prove  to  be  unsuited  for  disarticulation. 

2.  The  least  possible  division  of  the  muscles  is  made. 

3.  Disarticulation  is  easily  effected. 

4.  The  posterior  circumflex  artery  is  not  divided. 

5.  The  main  vessels  are  easily  secured. 

6.  A  very  excellent  stump  results. 

In  Larrey's  operation  the  parts  can  be  divided  as  neatly 
and  as  certainly  as  in  the  method  just  named,  and  in  any  case 
in  which  Spence's  measure  may  not  be  applicable  this  disarti- 
culation may  be  carried  out. 

A  preliminary  examination  of  the  joint  can  be  made,  and 
an  excision  effected  if  necessary,  but  the  articulation  is  exposed 
at  some  depth,  and  a  considerable  section  of  the  muscular 
tissues  is  made.  Moreover,  the  posterior  circumflex  artery  is 
apt  to  be  cut.     A  most  admirable  stump  results. 

The  disarticulation  by  the  external  flap  is  simple  and  easy, 
and  can  be  carried  out  Avith  rapidity. 

It  does  not  lend  itself,  however,  to  a  preliminary  exploration 
of  the  joint.  The  circumflex  artery  is  divided  and  the  flap  is 
apt  to  be  ill-nourished.  The  resulting  stump  is  not  a  good  one. 
The  flap  is  ill-fitting,  and  the  soft  parts  do  not  mould  them- 
selves to  the  glenoid  cavity  and  scapula. 


396  OPERATIVE    SURGERY. 

In  all  these  operations  it  may  be  claimed  that  excellent 
drainag-e  is  provided  for. 

The  After-treatment  of  these  Operations. — A  drainage- 
tube  will  be  required,  as  a  considerable  amount  of  fluid 
commonly  escapes  from  the  synovial  membrane  which  is  left 
behind. 

Pressure  should  be  applied  to  the  outer  flap  after  the 
stitches  have  been  mtroduced,  in  order  that  the  great  cavity 
left  beneath  the  acromion  may  be,  as  far  as  possible, 
obhterated. 

The  method  advised  by  Farabeuf  for  the  adjustment  of  the 
wound  after  Larrey's  operation  is  very  excellent. 

The  median  part  of  the  wound  is  united  by  sutures  as 
usual.  The  lower  extremity  is  left  open,  to  permit  of  efficient 
and  simple  drainage.  The  upper  portion  of  the  wound  is  not 
united  by  sutures,  but  the  edges  of  the  incision  are  brought 
together  by  a  compress.  This  compress,  which  is  applied  on 
the  outer  aspect,  not  only  supports  the  wound,  but  also  forces 
the  integuments  under  the  acromion,  and  obhterates  the 
hollow  about  the  glenoid  fossa. 

The  patient's  thorax  should  be  kept  raised,  and  the  body 
inclined  a  little  towards  the  injured  s'de. 


387 


CHAPTER    XXL 

Amputation  of  the  Upper  Limb  together  with  the 
Scapula. 

This  operation,  tlie  amputation  interscapulo-thoracique 
of  French  suro^eons,  has  been  carried  out  with  consider- 
able  success  in  some  few  cases  of  extensive  injury  of 
the  upper  extremity,  including  gunshot  wounds,  and  in  a 
larger  number  of  examples  of  malignant  tumour,  involving  the 
region  of  the  axilla  and  shoulder-joint,  the  complete  removal 
of  which  could  not  be  eifected  without  the  sacrifice  both  of 
the  arm  and  of  the  scapula.  It  has  been  performed  also  in 
examples  of  extensive  bone-disease. 

A  very  elaborate  account  of  the  operation  was  published 
by  Paul  Berger  in  1887,  and  the  monograph  includes  the 
histories  of  lifty-one  cases.  The  operation  appears  to  have 
been  first  performed  in  1808  by  Ralph  Gumming,  a  surgeon  m 
the  British  Navy.  Mr.  Chavasse  has  appended  to  an  account 
of  a  successful  operation  a  list  of  44  cases  in  which  the 
amputation  was  performed  for  neopiasmata ;  out  of  the  44 
cases  10  may  be  counted  as  cured  (Med.-Chir.  Trans., 
voL  IxxiiL,  1890).  The  mortaUty  in  the  non-traumatic  cases 
has  been  20  per  cent.,  and  in  the  traumatic  cases  30f  per  cent. 
The  chief  risks  of  the  operation  are  from  shock,  haemorrhage, 
the  entrance  of  air  into  veins,  and  from  purulent  infection. 

The  amputation  involves  ^he  removal  of  the  upper  Hmb, 
together  with  the  scapula  and  the  outer  two-thirds  of  the 
clavicle.  No  disarticulation  is  attempted  at  the  shoulder- 
joint. 

Method. — The  best  method  is  that  of  Paul  Berger  by  two 
flaps — an  antero-inferior  or  pectoro-axillary  flap,  and  a  posterior- 
superior  or  cervico-sc  ipular  flap. 

The  Steps  of  the  Operation. — The  amputation  may  be 
divided  into  four  stagres. 


39S  OPERATIVE    SURGERY. 

1st.  The  clavicle  is  exposed  and  is  divided  at  the  junction 
of  the  middle  Avith  the  inner  third.  The  middle  third  of  the 
bone  is  excised.  The  subclavian  vessels  are  exposed,  and  are 
secured  by  double  ligatures  and  divided. 

2nd.  The  antero-inferior  flap  is  fashioned  and  the  brachial 
plexus  severed. 

Srd.  The  postero-superior  flap  is  fashioned. 

4>th.  The  extremity  is  removed  by  dividing  the  tissues  still 
connecting  the  scapula  with  the  trunk. 

Instruments. — A  strong,  stout  amputating-knife  with  a 
blade  from  five  to  six  inches  in  length ;  a  stout  scalpel ;  a 
periosteal  elevator  curved  on  the  flat ;  metal  retractors,  spatulae, 
and  blunt  hooks  ;  a  keyhole-saw  or  a  fine  chain-saw  ;  bone 
forceps,  Hon  forceps,  aneurysm  needle,  pressure  forceps,  artery 
and  dissecting  forceps,  scissors,  etc. 

Position. — The  position  of  the  surgeon  varies  with  each  step 
of  the  operation,  and  is  described  below.  Three  assistants 
should  be  at  his  service. 

The  Operation. — 1st  Step. — The  patient  lies  upon  the 
back,  close  to  the  edge  of  the  operating-table.  The  shoulders 
are  raised  upon  a  hard  cushion.  The  arm  is  by  the  side  or  a 
little  separated  from  it.  The  surgeon  stands  to  the  outer  side 
of  the  limb,  facing  the  patient.  Two  assistants  are  placed 
one  on  each  side  of  the  surgeon.  A  third  assistant  stands 
on  the  other  side  of  the  body  and  facing  the  operator. 

The  clavicular  incision  is  now  made  with  a  stout  scalpel. 
The  incision  is  horizontal,  is  made  along  the  surface  of  the 
bone,  connnences  internally  at  the  outer  border  of  the  stcrno- 
mastoid  muscle,  and  ends  externally  just  beyond  the  acromio- 
clavicular articulation. 

The  knife  divides  everything  down  to  the  bone. 

At  this  stage  the  sometimes  large  connecting  vein  which 
may  pass  between  the  external  jugular  and  cephalic  veins  may 
be  severed. 

The  periosteum  of  the  clavicle  is  divided  along  the 
horizontal  line  corresponding  to  the  original  wound,  and  is 
also  divided  vertically  or  circularly  at  the  inner  extremity  of 
the  wound. 

The  inner  third  of  the  clavicle  is  not  disturbed  in  any  way. 

By  means  of  a  small  rugine  or  periosteal  elevator  curved 


INTERSCAPULO-THOBAGIC    AMPUTATION.  399 

on  the  flat,  the  periosteum  is  separated  from  the  superficial 
part  of  the  middle  portion  of  the  bone,  which  is  now  well 
exposed. 

During  the  use  of  the  elevator  an  assistant  should  steady 
the  collar-bone,  and  render  it  as  prominent  as  possible. 

A  large,  blunt  hook  may  now  be  very  carefully  passed 
round  the  inner  end  of  the  exposed  clavicle,  and  while  an 
assistant  draAvs  the  bone  forward  and  steadies  it  by  means  of 
this  hook  the  surgeon  saAvs  it  through  at  about  the  junction 
of  the  middle  with  the  inner  third.  The  section  is  accom- 
plished by  means  of  a  keyhole-saw,  or  by  a  fine  chain-saw,  the 
former  beinfr  the  more  convenient. 

The  blunt  hook  serves  to  guide  the  saw  and  in  some  way 
to  protect  the  deeper  parts.  During  the  sawing  the  middle  of 
the  clavicle  should  be  grasped  and  fiuther  fixed  by  means  of  lion 
forceps.  The  bone  is  the  more  conveniently  divided  (with  the 
hand-saw)  if  the  blade  be  directed  downwards,  outwards  and 
backwards.  A  perfectly  straight  vertical  section  of  the  bone 
is  difficult  and  unnecessary. 

The  outer  fragment  of  the  divided  clavicle  is  now  drawn 
forwards  by  the  Hon  forceps,  the  remaining  periosteum  is 
separated  from  its  posterior  and  deep  surfaces,  and  the  bared 
bone  is  then  again  sawn  through  at  the  outer  end  of  the 
middle  third. 

The  middle  third  of  the  clavicle  is  thus  entirely 
removed.  The  exposed  subclavius  muscle  is  now  isolated,  is 
divided  close  to  the  site  of  the  inner  section  of  the  bone,  and 
is  dissected  up  so  as  to  expose  the  great  vessels,  and  turned 
outwards. 

Fasciae  of  varying  thickness  will  have  to  be  divided  before 
the  vessels  are  reached. 

A  double  ligature  is  passed  round  both  the  artery  and  the 
vein,  and  between  the  ligatures  each  vessel  is  divided. 

The  ligature  takes  place  at  the  lower  border  of  the  first  rib 
and  the  artery  should  be  exposed  and  secured  before  the  vein, 
in  order  that  as  little  blood  as  possible  may  be  left  in  the 
extremity. 

Iiid  Step. — "Wliile  the  patient  is  still  lying  on  the  back 
the  body  is  brought  as  near  to  the  couch  as  possible,  and  the 
shoulder  is  made  to  project  beyond  it. 


400 


OPEBATB^E    SURGERY. 


An  assistant  di'aws  the  upper  limb  away  from  the  body, 
and  the  surgeon  stands  to  the  inner  side  of  the  hmb,  i.e., 
between  it  and  the  trunk.  The  whole  of  the  scaj3ular  region 
should  be  free  of  the  table,  the  back  resting  upon  the  hard 
cushion,  which  is  at  the  very  edge  of  the  table,  and  the  head 
being  drawn  to  the  opposite  side. 

The  assistant  moves  the  Hmb  as  requhed  during  the 
cutting  of  the  pectoro-axillary  flap. 


Fig 


1.— INTEESCAPULO-THOKACIC  AlIPUTATION. 


The  incision  marking  out  this  flap  is  commenced  at  the 
centre  of  the  clavicular  incision,  is  then  curved  downwards  and 
outwards,  passing  just  beyond  {i.e.,  to  the  outside  of)  the 
coracoid  process,  and  then  runs  along  the  deltoid  muscle, 
parallel  to,  but  to  the  outer  side  of,  the  groove  between  that 
muscle  and  the  pectoralis  major  (Fig.  98).  On  reaching  the  point 
where  the  anterior  wall  of  the  axilla  joins  the  arm,  the  incision 
crosses  the  loAver  margin  of  the  pectoralis  major,  and  passing 
transversely  across  the  skin  upon  the  inner  or  axillary  surface 
of  the  arm,  reaches  the  lower  margin  of  the  tendons  of  the 
latissimus  dorsi  and  teres  major.  At  this  point  the  limb  is 
weU  raised  by  the  assistant,  and  the  wound  is  completed  by 
carrying  the  knife  do\vnwards  and  inwards  to  stop  over  the 
posterior  surface  of  the  inferior  angle  of  the  scapula.  In  the 
last  part  of  the  course  the  knife  follows  the  groove  between  the 


INTEBSCAPULO-THOJRACIG  AMPUTATIOX.  401 

vertebral  border  of  the  scapula  and  the  muscular  mass  formed 
by  the  teres  major  and  latissimus  dorsi. 

The  incision  involves  at  first  only  the  skin  and  the  sub- 
cutaneous tissues. 

The  surgeon  now  dissects  up  the  structures  of  the  flap  which 
comprise  the  soft  parts  of  the  pectoral  and  axillar}^  regions. 

The  pectorahs  major  is  divided  about  where  it  is  becoming 
tendinous,  the  pectoralis  minor  is  severed  close  to  the  coracoid 
process.  An  assistant  holds  back  the  tissues  of  the  flap,  while 
the  surgeon  exposes  the  cords  of  the  brachial  plexus,  which  are 
then  divided  at  the  same  level  as  the  main  vessels,  i.e.,  close  to 
the  first  rib. 

The  shoulder  now  falls  outwards  away  from  the  trunk,  and 
the  axilla  is  fully  opened  up.  Any  undivided  connections  of 
the  limb  in  the  axillary  region  are  freed. 

The  latissimus  dorsi  is  severed  in  the  line  of  the  mcision, 
and  serves  to  form  part  of  the  flap. 

Srd  Step. — The  patient  lies  still  in  the  same  position  at 
the  extreme  edge  of  the  table  ;  but  the  arm  is  now  carried 
across  the  chest  by  an  assistant  so  as  to  well  expose  the 
scapular  region,  and  the  surgeon  takes  his  place  to  the 
outer  side  of  the  extremity. 

He  proceeds  to  cut  the  postero-superior  flap. 

The  incision  starts  at  the  outer  termination  of  the  first  or 
clavicular  incision  (i.e.,  at  a  point  just  beyond  the  acromio- 
clavicular joint),  and  is  carried  backwards  by  the  shortest  route 
over  the  scapular  spine  to  meet  the  termination  of  the  anterior 
flap  incision,  at  the  inferior  angle  of  the  scapula  (Fig.  98). 
The  wound  concerns  the  integuments  only.  The  skin  is  wxll 
reflected  in  the  upper  part  of  the  incision,  so  as  to  lay  bare  the 
trapezius  muscle.  This  muscle  is  divided  close  to  its  at- 
tachments to  the  clavicle  and  scapula,  and  is  entirely  severed 
from  its  connections  with  the  limb. 

Uli  Step. — Nothing  now  remains  but  to  sever  the  connec- 
tions of  the  scapula  with  the  trunk. 

One  assistant  holds  back  the  anterior  flap,  another  the 
posterior.  The  limb  is  allowed  to  hang  away  from  the  side, 
supported  by  a  third  assistant,  and  steadied  and  directed  by  the 
left  hand  of  the  operator. 

The  operator  himself  may  conveniently  stand  to  the  inner 


402  OPEEATIVE    SVBGERY. 

side  of  the  right  arm  and  the  outer  side  of  the  left.  The 
superior  and  vertebral  borders  of  the  scapula  being  made 
prominent,  the  following  muscles  are  rapidly  divided  from 
above  doTVTLwards  close  to  the  bone :  the  omo-hyoid,  levator 
anguh  scapulcie,  rhomboideus  minor  and  major,  and  the  serratus 
magnus. 

The  hmb  is  now  free.  The  two  teres  muscles,  the  sub- 
scapularis,  and  the  supra-  and  infra-spinatus  muscles  go  un- 
touched with  the  amputated  extremity. 

Ucemorrhage. — The  early  Hgature  of  the  main  vessel 
renders  the  bleeding  in  this  formidable  operation  com- 
paratively slight.  In  resecting  the  clavicle  and  exposing 
the  great  vessels  no  noteworthy  bleeding  is  encountered.  In 
fashioning  the  anterior  flap  hEemorrhage  may  be  expected  from 
several  muscular  arteries  and  fi'om  branches  of  the  acromio- 
thoracic  and  long  thoracic.  The  subscapular  artery  should 
not  be  disturbed,  although  its  thoracic  branch  -will  be  divided. 

In  fashioning  the  posterior  flap  no  vessels  of  any  note 
will  be  encountered  except  muscular  branches  in  the  trapezius 
muscle,  which  are  divided  as  the  muscle  is  cut. 

It  is  durmg  the  fourth  step  of  the  operation  that  most 
haemorrhage  is  to  be  expected.  It  wiU  come  from  the  vessels 
descending  from  the  neck  or  from  the  supra-scapular  and  the 
posterior  scapular.  The  former — a  small  artery  the  size  of 
the  hngual — may  be  secured  close  to  the  omo-hyoid  muscle, 
and  as  it  is  about  to  pass  into  the  supraspinous  fossa.  The 
posterior  scapular,  a  somewhat  larger  vessel,  reaches  the 
superior  angle  of  the  scapula  by  following  the  levator  anguli 
scapulae  muscle.  The  vessel  may  be  cut  and  clamped  im- 
mediately after  division  of  the  muscle. 

After -treatment. — The  wound,  when  closed  with  sutures, 
forms  an  oblique  line  running  from  above  downwards,  out- 
wards and  backwards.  A  large  pocket  is  left  in  the  stump, 
in  which  inflammatory  exudations  may  readily  collect.  This 
pocket  should  be  obhterated  by  pressure,  a  matter  best 
accomphshed  by  packing  the  wound  with  sponges,  over  which 
the  pressure  of  a  bandage  is  brought. 

If  this  be  well  effected,  and  if  no  diseased  or  damaged 
tissue  have  been  left  behind,  a  drainage-tube  is  not  required. 
The  patient  should  be  kept  weU  raised  up  in  bed. 


403 


CHAPTER    XXII. 

Amputation  of  the  Toes. 

As  in  the  majority  of  cases  amputation  of  the  toes  is 
performed  for  injury,  it  is  not  always  possible  to  carry  out 
the  precise  lines  of  a  formal  operation.  In  not  a  few  instances 
the  '•'  amputation "  consists  merely  in  removing  a  Httle  bone 
and  in  trimming  a  mangled  stump. 

Anatomical  Points. — The  two  outer  toes — and  possibly 
the  third  toe — are  commonly  found  to  be  much  bent  upon 
themselves,  and  not  lying  straight  as  shown  in  surgical 
diagrams.  This  bending  consists  in  a  flexing  of  the  last 
phalanx  or  of  the  last  two  phalanges  upon  the  first. 

The  joints  of  the  toes  should  be  defined.  The  middle  of 
the  length  of  each  toe  about  corresponds  to  the  joint  between 
the  first  and  second  phalanges.  The  line  of  the  metatarso- 
phalangeal joints  follows  an  easy  curve,  and  is  about  one  inch 
behind  the  web  of  the  toes.  The  head  of  the  first  metatarsal 
bone  and  the  line  of  its  joint  can  be  readily  made  out  by  a 
little  manipulation.  The  heads  of  the  first  and  of  the  third 
metatarsals  are  in  the  same  transverse  line.  The  head  of  the 
second  is  about  3  m.m.  in  front  of  this  line,  and  the  head 
of  the  fourth  about  3  m.m.  behind  it ;  while  the  head  of 
the  fifth  metatarsal  is  a  little  more  than  1  cm.  (nearly  half 
an  inch)  behind  the  luie. 

The  last  phalanges  of  the  four  outer  toes  are  small,  squat 
bones,  often  nearly  square,  and  an  amputation  "  through  "  the 
last  phalanges  of  these  toes  would  in  many  instances  be  an 
absurdity.  The  shafts  of  the  first  and  second  phalanges  are 
slender  and  compact,  and  can  be  easily  divided  with  bone 
forceps.     {See  page  306.) 

Each  phalanx  has  one  epiphysis  at  its  proximal  extremity 
It  is  represented  by  the  base  of  the  bone,  and  joins  the  shaft 
between  the  nineteenth  and  twenty-first  years. 

A  A   2 


404  OPEEATIVE    SURGERY. 

The  prominent  part  of  each  phalangeal  joint — each 
knuckle — is  formed  by  the  head  of  the  proximal  bone. 

The  inter-phalangeal  and  metatarso-phalangoal  joints  are 
each  supported  by  two  lateral  ligaments  and  a  glenoid  liga- 
ment. The  former  are  nearer  to  the  plantar  than  the  dorsal 
aspect  of  the  joint.  The  tough,  fibrous,  glenoid  ligament 
occupies  the  whole  of  the  plantar  aspect  of  the  joint.  The 
head  of  the  proximal  bone  rests  on  it ;  the  lateral  ligaments 
join  it ;  it  is  more  firmly  attached  to  the  base  of  the  distal 
bone  than  the  head  of  the  proximal  one.  Beneath  it  glides 
the  flexor  tendon,  the  fibrous  sheath  of  which  is  fixed  to  it. 
In  the  glenoid  hgament  of  the  first  metatarso-phalangeal 
joint  two  sesamoid  bones  are  developed.  They  are  received 
in  grooves  on  the  head  of  the  metatarsal  bone,  but  their  more 
intimate  structural  connection  is  with  the  phalanx.  The 
fibrous  sheaths  for  the  flexor  tendons  have  the  same  arrange- 
ment in  the  foot  as  in  the  hand,  and  the  same  care  should 
be  taken  to  effectually  close  them  when  divided.  (See  page 
322.) 

In  dealing  with  the  anterior  part  of  the  foot  it  must  be 
remembered  that  the  foot  rests  upon  the  heel,  the  heads  of 
the  metatarsal  bones,  and  the  inner  margin  of  the  sole.  In 
amputation,  therefore,  every  care  should  be  taken  to  save  as 
much  as  possible  of  the  metatarsus,  and  especially  of  the  first 
metatarsal  bone  and  the  phalanges  of  the  great  toe.  The 
same  care  need  not  be  taken  to  preserve  every  possible  part  of 
the  four  outer  toes.  A  sloughing  stump  has  often  resulted 
from  too  great  anxiety  to  preserve  these  almost  useless  digits. 

Instruments. — Stout,  narrow  scalpels,  with  blades  from  one 
inch  to  two  mches  in  length,  and  with  well-rounded  points. 
A  fine  keyhole-saw,  or  minute  Butcher's  saw.  Bone  forceps. 
Dissecting  and  artery  forceps.  Tapes  to  retract  the  toes. 
Scissors,  needles,  etc. 

Position. — In  all  these  operations  upon  the  toes  the 
patient  should  lie  on  the  back,  and  the  foot  be  brought 
well  beyond  the  end  of  the  couch.  The  surgeon  should  sit 
at  the  end  of  the  table  facing  the  patient.  The  assistants 
stand — facing  the  surgeon — one  on  each  side  of  the  end  of 
the  table.  One  should  fix  the  limb  and  hold  the  toe,  while 
the  other  attends  to  the  wound. 


AMPUTATION   OF  TOES.  405 

Tlie  operations  included  in  this  chapter  will  be  dealt  with 
in  the  following  order : — 

A.  Amputation  of  the  distal  phalanges. 

B.  Disarticulation  at  the  metatarso-phalangeal  joints. 

C.  Amputation  of    the  toes   en   masse   through    the 

metatarsus. 

A. — AMPUTATION   OR   DISARTICULATION  OF  THE   DISTAL 
PHALANGES   OF   THE   TOES. 

1.  Disarticulation  of  the  Last  Phalanx  of  the  Great  Toe. 

— Large  Plantar  Flap. — Hold  the  toe  between  the  thumb  and 

first  two  fingers  of  the  left  hand — the  thumb  on  the  pulp  of 

the  toe,  the  fingers  on  the  nail. 

Cut  the  plantar  flap  as  the  toe 

is  thus  held.     Enter  the  knife — 

at  right  angles  to  the  surface — 

just  over  the  head  of  the  first 

phalanx.     Cut  along  the  side  of 

the   toe  to  the   pulp.     This   in-     Fig.  99.— disarticdlatton  op  the 

^  111  n     1      ^         ^1  LAST     PHALANX      OF      THE     GREAT 

cision  should  be  parallel  to  the        toe  by  a  large  plantar  flap. 
phalanx,  and  nearer  to  the  dorsal 

than  the  plantar  aspect.  Shape  the  flap  as  shown  (Fig.  99) 
and  return  to  the  same  point  on  the  opposite  side.  The  in- 
cision should  extend  down  to  the  bone. 

Let  the  assistant  forcibly  extend  *  the  last  phalanx  while 
the  flap  is  dissected  back,  it  being  held  by  the  left  hand 
while  so  doing.  In  making  this  flap  the  surgeon  must  keep 
as  close  as  possible  to  the  bono.  When  the  glenoid  ligament 
is  reached,  cut  it  transversely  against  the  base  of  the  last 
phalanx.     The  joint  is  thus  opened. 

Now  let  the  surgeon  forcibly  flex  the  toe  and  make  a 
transverse  cut  across  the  dorsum  that  at  once  divides  the 
extensor  tendon  and  opens  the  joint.  Rotate  the  toe  out, 
and  carefully  divide  the  internal  lateral  ligament.  Rotate  it 
in  and  divide  the  external  band,  and  the  disarticulation  is 


*  To  avoid  confusion  of  terms  this  note  may  be  given  :  Flexion  of  a  toe— the 
bending  of  the  toe  towards  the  sole— action  of  the  flexor  muscles.  Flexion  of 
the  foot=thc  bending  of  the  foot  at  the  ankle  so  that  the  toes  are  brought  nearer 
to  the  shin — action  of  extensor  muscles. 


406  OPERATIVE    SURGERY. 

complete.  In  disarticulating,  keep  the  loiife  very  close  to  the 
bone,  so  as  to  aA^oid  wounding  the  plantar  digital  arteries. 
Cut  the  lateral  lio-aments  from  without  inwards.  The  cicatrix 
of  the  stump  will  come  well  on  the  dorsum. 

The  long  plantar  flap  should  not  be  cut  by  transfixion. 
By  so  doing  the  vessels  are  needlessl}^  damaged. and  the  flap 
is  apt  to  be  scanty.  If,  on  the  other  hand,  too  large  a  flap 
be  cut,  a  pocket  is  made  for  pus. 

HcviQiorrhage. — The  two  dorsal  digital  arteries  will  be  cut 
at  the  corners  of  the  dorsal  incision.  They  are  small,  and 
usually  do  not  need  to  be  secured.  If  the  flap  has  been  well 
cut,  the  two  plantar  digital  arteries  -will  not  be  wounded,  but 
\nR  he  buried  in  the  flap  until  they  anastomose  at  its  free 
end.  They  may  readily  be  cut  if  in  dissecting  the  flap  back 
the  linife  is  not  kept  close  to  the  bone.  They  also  he  near  to 
the  sides  of  the  joint  (plantar  aspect)  and  may  be  easily 
wounded  in  careless  disarticulation. 

In  amputation  through  tlte  last  phalanx  of  the  great  toe 
the  same  operation  should  be  emj)loyed,  the  dorsal  incision 
being  made  nearer  the  nail.  It  should  be  a  rule  that  no 
more  of  the  great  toe  should  be  removed  than  is  absolutely 
necessary.  An  endeavour  should  be  made,  when  possible,  to 
spare  the  base  of  the  second  j3halanx.  By  so  doing  the  jomt 
is  undisturbed,  and  the  insertions  of  the  flexor  and  extensor 
tendons  are  saved. 

2.  Amputation  or  Disarticulation  of  the  Distal  Phalanges 
of  the  Four  Outer  Toes.— In  operating  upon  the  smaller  toes 
the  ncighbourmg  digits  should  be  held  aside  by  the  assistant 
by  means  of  tapes.     It  is  well  not  to  use  too  long  a  scalpel 

The  terminal  phalanges  may  be  removed  by  the  operation 
just  described. 

In  disaHiculation  of  the  second  phalanx  use  the  oval  or 
racket  incision.  Grasp  the  toe  with  the  left  hand  and 
flex  it.  Enter  the  knife  1  cm.  above  the  jomt  and  in  the 
median  dorsal  line.  Continue  the  incision — which  should  be 
only  skin-deep — along  to  the  middle  of  the  second  phalanx. 
Now  curve  it  down  to  the  plantar  margin,  cutting  to  the  bone. 
Forcibly  extend  the  toe  and  draw  the  knife  transversely 
across  its  plantar  aspect.  Still  cut  to  the  bone,  and  so  make  a 
good  division  of  the  flexor  tendon.     Cut  up  on  the  opposite 


AMPUTATION  OF  TOES. 


407 


L..a 


Fig.  100. — A,  Disarticulation  of  the 
second  phalanx  of  a  toe  by  the 
racket  or  oval  incision ;  B,  Dis- 
articulation of  the  great  toe  by 
the  racket  or  oval  incision. 


side  of  the  toe  to  meet  the  straight  dorsal  incision  (Fig.  100,  a). 
In  this  step  cut  also  to  the  bone. 

Now  let  the  assistant  forcibly  extend  the  toe ;  dissect  up 
the  lateral  and  plantar  parts  of  the  cut ;  divide  the  glenoid 
ligament  transversely  against  the  base  of  the  second  phalanx 
and  thus  open  the  joint.     Then 
divide  the  lateral  ligaments,  and 
nothing  will  retain  the   toe  but 
the  extensor  tendon.     Pull  upon 
"Jie   toe   and   divide  this  tendon 
as  high  up  as  convenient.     Close 
the  sheath  of  the   flexor   tendon 
(page  322).     The  cicatrix  mil  be 
vertical,  i.e.,  dorso-plantar. 

Hcemorrhage.  —  Two  dorsal 
and  two  plantar  digital  arteries 
are  found  cut  in  the  lateral 
edges  of  the  wound.  The  dorsal 
will  require  no  attention,  the 
latter  may  be  twisted. 

In  amjjutation  through  the  first  phalanx  employ  the 
cu'cular  method.  Make  a  circular  cut  round  the  phalanx 
at  the  level  of  the  web ;  cut  to  the  bone.  As  the  knife  crosses 
the  dorsum,  flex  the  toe  so  as  to  cut  the  extensor  tendon 
short.  As  the  scalpel  crosses  the  plantar  aspect,  extend  the 
digit  to  its  utmost.  Separate  the  soft  parts  from  the  phalanx 
as  high  up  as  possible,  and  divide  the  bone.  Close  the  sheath 
of  the  flexor  tendon  (page  322).  The  vessels  are  cut  as  in  the 
last  instance.  The  cicatrix  should  be  vertical,  i.e.,  dorso- 
plantar.  Amputation  through  the  first  phalanx  may  also  be 
effected  by  two  lateral  flaps  of  equal  size  cut  by  transfixion 
with  a  narrow  bistoury. 

ComTnent. — The  phalanges  of  the  four  outer  toes  are  of 
little  use  ;  their  absence  is  usuall}^  not  unpleasantly  felt. 

In  disarticulating  the  second  phalanx,  I  should  remove 
the  head  of  the  first  phalanx,  or  replace  the  operation  by  an 
amputation  through  the  latter  bone  at  the  level  of  the  web. 
The  head  of  the  first  phalanx  is  large,  and  is  apt  to  play  the 
part  of  a  foreign  body  between  the  other  toes  when  it  is  left. 
Its  removal  is  no  detriment  to  the  use  of  the  foot. 


408 


OPERATIVE    SURGERY. 


As  lias  been  observed  elsewhere  (page  306),  the  bone  should 
be  divided  by  a  very  fine  saw  rather  than  crushed  by  forceps. 

For  the  treatment  of  the  tendon-sheaths  in  some  of  these 
amputations,  see  page  322. 

B. — DISARTICULATION    AT    THE    METATARSO-PHALANGEAL 

JOINTS. 

1.  Disarticulation  of  the  Great  Toe  at  the  Metatarso- 
phalangeal Joint. 

In  this  operation  notice  must  be  taken  of  the  very  large 
size  of  the  head  of  the  metatarsal  bone.     Its  dimensions  are 
increased  by   the   presence   of    the   sesamoid  bones,   which 
should  never  be  removed  with  the  phalanx.     It  is  of  con- 
siderable  importance  to  the  future  use   of 
the  foot  that  the  head   of  the   metatarsal 
bone   should  be  preserved,   and  it  will   be 
seen  that  the  chief  difficulty  of  the  opera- 
tion is  to  provide  flap  enough  to  cover  the 
projection.      It  is  important  also  that  the 
scar    should    be    away   from    the    plantar 
surface     and    the    line    of     the    sesamoid 
bones. 

The  joint  can  be  readily  made  out  by 
manipulation,  especially  on  the  inner  aspect 
of  the  foot.  It  is  placed  about  an  inch 
behind  the  web.  The  projection  of  the 
sesamoids  can  also  very  easily  be  defined. 

The  followmg  are  the  chief  methods  of 
operation : — 
(1)  By  Interval  Plantar  Flap  (Farabeuf). — The  surgeon 
sits  to  the  front  and  the  inner  side  of  the  foot.  The  four  sur- 
faces of  the  digit — dorsal,  plantar,  internal,  and  external — 
should  be  noted  and  conceived  to  be  each  of  equal  extent.  The 
joint-line  is  made  out,  and  the  toe  being  grasped  with  the  left 
hand,  the  knife  is  entered  over  that 'line  and  at  a  point 
where  the  dorsal  and  internal  surfaces  meet.  An  incision, 
2  cm.  in  length,  is  made  along  the  toe,  parallel  to  the  ex- 
tensor tendon  and  on  the  line  between  the  two  surfaces 
named.  It  is  then  curved  downwards  over  the  inner  surface 
to  the  plantar  margm  (Fig.  101).     The  toe  is  now  turned  in, 


-DIS.'\ETIC- 


Fig.   101. 

UL.\TION  OF  THE 
GREAT  TOE  BY  IN- 
TERNAL PLANTAR 
FLAP. 


AMPUTATION  OF  TOES. 


409 


and  the  knife,  placed  beneath  the  member,  is  drawn  across 
the  plantar  surface  to  the  edge  of  the  web  between  the  toes. 
The  knife  is  now  held  above  the  toe,  and  the  incision  com- 
pleted by  a  cut  to  the  point  of  starting,  made  by  the  shortest 
route.  The  whole  of  this  incision  should  involve  the  skin 
only. 

It  should  now  be  deepened  down  to  the  bone  in  the  same 
order.  In  drawing  the  knife  across  the  plantar  surface,  extend 
the  toe,  so  as  to  cut  the  flexor  tendon  high  up.  Dissect  back 
the  flap,  keeping  close  to  the  bone.  In  so 
doing,  the  assistant  should  hold  the  toe  and 
turn  it  to  one  or  other  side  as  required, 
while  the  surgeon  uses  his  left  fingers  to 
turn  back  the  soft  parts.  Separate  the 
tissues  about  the  point  of  starting;  clear 
the  soft  parts  from  the  surface  of  the  joint. 
Forcibly  extend  the  toe,  and  cut  the  glenoid 
ligament  transversely  close  to  the  base  of 
the  phalanx.  The  joint  is  thus  opened ; 
the  ligament,  with  the  sesamoid  bones, 
remains  behind.  Divide  the  lateral  liga- 
ments, and  finally  cut  the  extensor  tendon. 
Close  the  fibrous  sheath  for  the  flexor 
tendon  (page  322). 

Hcemorrhage. — The  outer  plantar  digi- 
tal artery  will  be  found  cut  close  to  the  web,  the  inner  vessel 
at  the  free  end  of  the  inner  flap.  The  dorsal  digital  vessels 
will  probably  not  need  to  be  secured. 

The  flap  is  adjusted  as  shown  (Fig.  102). 

(2)  By  Racket  or  Oval  Incision. — The  toe  is  grasped 
by  the  left  hand.  The  knife  is  entered  about  1  cjn. 
above  the  metatarso-phalangeal  joint  in  the  dorsal  median 
line.  It  is  continued  down  to  the  centre  of  the  first  phalanx, 
and  when  carried  round  the  toe  to  form  the  racket  should 
just  avoid  the  web  (Fig.  100,  b).  The  proceeding  is  identical 
with  that  described  in  disarticulation  of  the  second  phalanx 
(page  406).  The  joint  should  be  opened  from  below,  through 
the  glenoid  ligament. 

The  fibrous  sheath  for  the  flexor  tendon  is  closed  (page  322). 

In  disarticulating,  the  toe  should  be  manipulated  by  the 


Fig.  10l>. — msAETicu- 

LATION  OF  THE 
GEEAT  TOE  BY  IN- 
TEENAIi  PLANTAE 
FLAP  :    THE  EESULT- 

ING  STUMP.  (Fara- 
beuf.) 


410 


OPERATIVE    SURGERY. 


assistant,  while  the  surgeon  holds  back  the  soft  parts  with 
his  left  fingers.  The  toe  should  be  turned  and  twisted  to  the 
inner  side  when  dividing  the  outer  lateral  ligament,  and  to 
the  outer  side  when  dividing  the  inner  one.  In  dissecting 
back  the  flap,  it  is  well  to  keep  close  to  the  bone,  so  as  to 
avoid  injury  to  the  digital  vessels. 

In  disarticulating,  also,  care  must  be  taken  to  keep  close  to 

the  phalanx  and  to  cut  towards  the  bone ;  the  soft  parts  must 

be  well  dissected  back  and  the  ligaments  exposed.    If  such  care 

be  not  taken,  the  j^lantar  digital  arteries — which  lie  close  to 

the  joint — wiU  be  divided.     The  cicatrix  comes 

i         OA^er  the  head  of  the  bone  and  is  vertical  to 

the  sole. 

The  digital  arteries  wiU  be  found  divided 
at  the  free  margin  of  the  flap  on  either  side. 

(3)  By  Internal  Flap. — The  surgeon  grasps 
the  toe  with  the  left  hand.  The  incision  is 
commenced  on  the  dorsal  as23ect,  about  2  m.m, 
below  the  joint-line  and  just  to  the  outside 
of  the  extensor  tendon.  It  is  continued 
straight  down  the  dorsum  of  the  toe  to  the 
level  of  the  interphalangeal  joint.  From  this 
point  a  transverse  cut  is  made  across  the 
dorsal,  internal,  and  plantar  aspects  of  the  toe 
to  the  outer  border  of  the  flexor  tendon  (Fig. 
103).  The  incision  is  now  carried  back  to  the  web  along  the 
outer  margin  of  this  tendon.  From  the  web  a  transverse  cut 
is  made  across  the  external  and  dorsal  surfaces  to  meet  the 
dorsal  incision,  which  it  joins  about  its  centre.  The  whole  of 
this  incision  should  at  first  involve  the  skin  only. 

.  The  internal  flap  is  now  dissected  up  from  below  upwards. 
The  knife  must  be  kept  close  to  the  bone.  The  extensor 
tendon  is  exposed  and  cut  over  the  joint-line  while  the  toe  is 
being  flexed.  The  joint  is  thus  opened,  the  lateral  ligaments 
are  cut,  and  a  final  plantar  incision — made  while  the  toe  is 
extended  to  the  utmost — divides  the  flexor  tendon  and  the 
glenoid  ligament.  Close  the  fibrous  sheath  of  the  flexor 
tendon  (page  322.) 

The  outer  digital  vessels  are  cut  close  to  the  web,  and  the 
inner  in  the  free  edge  of  the  inner  flap. 


Fig.    103.— DiSAE- 

TICUIiATIOX  OF 
THE  GEEAT  TOE 
BY  INTEENAL 
FLAP. 


AMPUTATION  OF   TOES.  411 

The  flaps  need  not  be  cut  t|uite  so  square  as  is  shown. 

The  cicatrix  comes  well  to  the  outer  side,  close  to  the  web, 
and  under  cover  of  the  second  toe. 

Comment. — Of  these  three  operations,  the  first  described 
is  undoubtedly  the  best.  The  cicatrix  is  out  of  the  line  of 
pressure  and  is  well  protected,  while  the  adjustment  of  the 
wound  is  such  that  excellent  drainage  is  permitted.  In  the 
oval  operation  the  cicatrix  comes  directly  over  the  head  of 
the  bone.  Good  drainage  is,  however,  permitted,  and  the 
operation  is  very  easily  carried  out.  It  may  claim  perhaps  to 
be  the  most  ready  of  the  three  procedures. 

The  disarticulation  by  internal  flap  is  not  so  convenient. 
The  flaj)  is  not  readily  made  and  is  a  httle  clumsy ;  the 
cicatrix,  however,  is  well  placed. 

In  all  these  disarticulations  great  care  must  be  taken  not 
to  cut  the  digital  arteries,  as  is  so  readily  done  in  clearing 
the  bones.  The  toe  has  no  other  source  of  blood-supply,  and 
if  the  vessels  are  cut  it  is  little  wonder  that  the  flaps  slough 
or  are  slow  in  healing.  The  artery  should  run  the  full  length 
of  the  flap. 

When  possible,  the  base  of  the  first  phalanx  of  the 
toe  should  be  saved,  on  account  of  the  important  series 
of  muscles  to  which  it  gives  attachment  (abductor  and  ad- 
ductor pollicis,  flexor  brevis  pollicis,  and  transversus  pedis). 
Although  these  muscles  can  no  longer  act  upon  the  toe,  they 
are  of  value  in  maintaining  the  strength  of  the  sole. 

The  skin  in  this  region  is  often  much,  thickened,  and  is 
consequently  unyielding,  and  in  adjusting  flaps  care  must  be 
taken  that  too  muck  strain  does  not  come  upon  the  sutures. 

2.  Disarticulation  of  the  Outer  Toes  at  the  Metatarso- 
phalangeal Joints. 

The  best  operation  is  that  by  the  oval  or  racket  incision 
already  described  (pages  329,  409).  Care  must  be  taken  that 
the  toes  on  either  side  of  the  one  to  be  removed  are  held  apart 
by  tapes  by  the  assistant. 

In  disarticulating  the  Httle  toe,  the  dorso-external  flap 
advised  by  Farabeuf  will  be  certainly  found  to  give  the  most 
convenient  stump.  Its  application,  however,  in  practice  must 
be  exceedingly  Umited. 

The  knife  is  entered  on  the  dorsuia,  just  below  the  joint. 


412 


OPERATIVE    SURGERY. 


and  to  the  inner  side  of  the  extensor  tendon.  The  incision 
follows  the  inner  edge  of  the  tendon  for  the  whole  length  of 
the  first  phalanx.  It  is  then  inclined  outwards  across  the 
outer  aspect  of  the  toe,  and  carried  back  to  the  level  of  the 
web.  By  this  means  a  U-shaped  flap,  with  unequal  hmbs, 
is  formed  from  the  structures  on  the  dorsal  and  external 
surfaces.  The  two  extremities  of  the  U  are  now  united  by  a 
cut  which  crosses  the  plantar  and  internal  aspects  of  the  toe, 
and  joins  the  dorsal  incision  by  the  shortest  route. 

The  cicatrix  that  results  from  this 
amputation  is  removed  from  pressure. 
It  lies  well  to  the  inner  side,  and  is 
protected  by  the  fourth  toe  (Fig.  104). 

The  importance  of  closingthe  tendon- 
sheaths  has  been  discussed  on  page  322. 
3.  Disarticulation  of  the  Toes  en 
masse  at  the  Metatarso-Phalangeal 
Joints. 

This  is  best  effected  by  short  dorsal 
and  plantar  flaps. 

The  operator  should  sit  at  the  end 
of    the   table,   facing   the   foot,   which 
should   project  some  way  beyond  the 
extremity  of  the  table. 
The    line  of  the   metatarso-phalangeal    joints    must    be 
defined  (page  403). 

The  chief  difficulty  in  the  operation  is  to  provide  a  suffi- 
cient covering  for  the  large  head  of  the  first  metatarsal  bone. 

Supposing  the  left  foot  to  be  the  one  dealt  Avith,  the 
operator  grasps  the  toes  with  the  left  hand,  his  thumb  being 
on  the  dorsum  and  his  fingers  on  the  plantar  surface.  The 
foot  is  turned  out,  and  the  knife  is  entered  just  over  the 
metatarso-phalangeal  joint  of  the  great  toe.  The  point  of 
entrance  should  be  midway  between  the  plantar  and  dorsal 
surfaces.  An  incision  is  now  made  from  this  point  along  the 
inner  side  of  the  foot.  It  is  longitudinal,  and  is  carried  as  far 
as  the  centre  of  the  first  phalanx. 

The  foot  is  now  extended  and  the  toes  are  gently  flexed,* 
while   the   incision   is   carried   abruptly  across   the   dorsum. 

*  Sec  foot-note,  page  405. 


Fig.  104. — DISAETICtTLATICN 
OF  THE  LITTLE  TOE  BY 
DOESO-EXTEENAL  FLAP  : 
THE      EEStrLTING     STUMP. 

{Faraheuf.) 


AMPUTATION  OF   TOES.  413 

The  cut  crosses  the  centre  of  the  first  phalanx  of  the  great 
toe  transversely,  and  then  follows  the  line  of  the  web. 

To  follow  the  hollows  between  the  toes,  the  operator  must 
separate  each  pair  a  little  with  his  left  fingers  as  he  proceeds. 
On  reaching  the  dorsum  of  the  little  toe,  the  incision  is 
carried  longitudinally  back  along  the  lateral  margin  of  the 
little  toe  to  the  level  of  the  metatarso-phalangeal  joint. 

This  incision  may  in  the  first  instance  involve  the  skin 
only.  The  dorsal  flap  thus  marked  out  must  be  dissected 
back.  The  assistant  takes  charge  of  the  toes,  which  he  keeps 
flexed ;  the  surgeon  has  his  left  hand  free  to  manipulate  the 
flap.  The  flap  should  contain  all  the  soft  parts  down  to  the 
extensor  tendons.  When  about  half  the  flaj)  has  been  dis- 
sected back  these  tendons  should  be  divided.  Before  each 
one  is  cut  the  corresponding  toe  should  be  flexed  to  its 
utmost  by  the  assistant.  The  flap  is  carried  back  until  the 
line  of  joints  is  exposed. 

The  plantar  flap  is  now  cut.  The  toes  are  held  in  the 
extended  posture  by  the  surgeon,  his  thumb  being  on  the 
plantar  aspect  and  his  fingers  on  the  dorsum. 

The  incision  is  simply  transverse,  and  joins  the  distal  ends 
of  the  two  lateral  incisions.  It  is  so  carried  across  the  foot 
as  to  follow  the  creases  which  separate  the  toes  from  the  sole. 
The  incision  should  extend  to  the  flexor  tendons.  The  flap 
is  dissected  back,  the  assistant  keeping  the  toes  extended. 
When  the  flap  is  about  half  made,  the  flexor  tendons  may  be 
divided,  and  the  whole  of  the  soft  parts  are  then  dissected 
back  to  the  Ime  of  joints. 

The  flaps  should  be  now  sufficiently  retracted  to  well 
expose  this  line.  The  articulations  having  been  opened  on 
the  dorsal  aspect,  the  lateral  ligament  of  the  first  joint  is 
divided;  the  toes  are  then  extended  fully,  and  the  line  of 
articulations  finally  opened  from  the  plantar  aspect.  The 
glenoid  ligaments  are  preserved.  The  disarticulation  should 
then  be  completed,  jomt  by  joint,  in  the  left  foot,  from  the 
inner  to  the  outer  side.  In  the  right  foot  the  incisions  are 
commenced  at  the  outer  side,  and  the  disarticulation  is  beoun 
at  the  joint  of  the  little  toe. 

The  sheaths  of  the  flexor  tendons  should  be  closed. 

Hcemorrhage. — The  plantar  digital  arteries  wiU  be  found 


4U 


OPERATIVE    SURGERY. 


divided  some  way  down  on  the  plantar  flap,  and  the  dorsal 
digital  at  about  the  same  place  on  the  dorsal  flap. 

The  latter  will  probably  not  need  to  be  secured.  • 

Comment. — This  is  a  dead-house  operation,  and  one  that 
can  scarcely  ever  be  required  in  the  living  subject.  It  may 
be  called  for  in  some  very  limited  cases  of  crushed  toes,  and 
possibly  in  some  instances  of  frost-bite. 

By  some  it  is  advised  that  the  lino  of  articulations  be 
opened  by  one  sweep  ("  by  a  sawing  movement ")  after  the 
flaps  have  been  cut.  Such  a  manoeuvre  would  be  rapid,  but 
at  the  same  time  clumsy,  and  calculated  to  damage  the  flaps 
and  the  heads  of  the  bones. 

Dubrueil  advises  a  more  or  less  circular  incision,  and  cuts 

a  U-shaped  flap  from  the  inner  side  of  the  great  toe  in  order 

that  the  head  of  the   first   metatarsal 

bone  may  be  effectually  covered  (Fig. 

105). 

C. — AMPUTATION   OF  THE  TOES  EN  MASSE 
THROUGH    THE   METATARSUS. 

This  operation  is  carried  out  upon 
the  same  principles  as  that  just  de- 
scribed. 

The  best  procedure  is  that  of  a 
long  plantOjT  flap.  The  foot  should 
project  beyond  the  end  of  the  table, 
and  the  surgeon  should  sit  facing  it. 
The  points  at  which  the  bones  are  to 
be  sawn  must  be  first  determined.  The 
saw-line  must  be  oblique,  so  as  to 
follow  the  natural  line  of  the  metatarsal 
bones ;  i.e.,  the  section  of  the  fifth  metatarsal  must  be  posterior 
to  the  section  of  the  first  metatarsal.  The  saw-cut,  in  fact, 
should  be  about  parallel  with  the  line  of  the  web.  The 
plantar  flap  may  be  cut  first.  This  is  done  with  the  foot 
well  flexed.* 

Assuming  the  left  foot  to  be  the  one  operated  on,  the  knife 
is  entered  at  the  inner  margin  of  the  foot,  midway  between 
the  dorsal  and  plantar  surfaces.      The   point  of   entrance  is 

'  See  foot-noto,  page  405. 


Fig.      lOo.  —  dubrueil's 

OPEEATIOX   FOn   THE  RE- 
MOVAL OF  ALL  THE  TOES. 


AMFUTATION  OF  TOES.  415 

over  the  first  metatarsal,  and  is  just  behind  the  point  at  which 
that  bone  is  to  be  divided.  The  incision  is  carried  along- 
the  side  of  the  foot  until  the  level  of  the  crease  that 
separates  the  great  toe  from  the  sole  is  reached.  It  is  now 
made  to  sweep  across  the  plantar  surface  just  behind  the 
web.  On  reaching  the  outer  surface  of  the  little  toe,  the 
incision  is  carried  back  along  the  margin  of  the  foot  until  a 
point  is  reached  just  posterior  to  the  spot  selected  for  the  sec- 
tion of  the  fifth  metatarsal  bone.  In  making  this  plantar  inci- 
sion the  surgeon  should  keep  the  foot  rigid  with  his  left  hand, 
and  at  first  the  cut  should  be  through  the  skin  only.  An 
assistant  now  takes  the  foot  and  keeps  it  well  flexed  at  the 
ankle,  while  the  surgeon  uses  his  left  fingers  to  aid  in  dissect- 
ing back  the  flap.  The  flexor  tendons  should  be  divided  as 
soon  as  the  separation  of  the  flap  has  been  well  commenced. 
While  they  are  being  cut  the  individual  toes  must  be  fully  ex- 
tended. 

The  plantar  flap  should  contain  all  the  soft  parts  down  to 
the  bone. 

The  foot  having  been  extended,  the  dorsal  incision  is 
made.  It  should  be  parallel  with  the  plantar  cut,  and  should 
join  the  lateral  parts  of  the  plantar  flap  about  one  inch 
from  their  points  of  commencement.  In  other  words,  this 
little  flap  is  about  one  inch  in  length.  The  flap  must  include 
all  the  soft  parts  down  to  the  bone.  The  extensor  tendons 
should  be  divided  when  the  flap  is  about  half  separated. 

In  dividing  the  bones,  the  plantar  flap  should  be  carefully 
protected  by  an  ivory  spatula.  Each  bone  should  be  sawn 
separately  from  the  dorsal  aspect  with  a  fine  narrow  saw. 
The  rude  crushing  of  the  bones  with  cutting  forceps  is  not 
to  be  advised. 

It  is  to  be  remembered  that  the  shafts  of  the  metatarsal 
bones  are  embraced  by  the  interossei  muscles.  These  must 
be  cleanly  divided  before  the  saw  is  applied. 

The  cicatrix  comes  upon  the  dorsum  of  the  foot. 

RcBmorrhage. — In  the  plantar  flap  six  arteries  (the  digital) 
may  possibly  require  to  be  secured.  One  will  be  found  oj^po- 
site  to  each  of  the  four  interosseous  spaces,  a  fifth  oppcsite 
the  outer  side  of  the  fifth  metatarsal,  and  a  sixth  opposite 
the  inner  side  of  the  first  metatarsal.     The  two  latter  vessels- 


416  OPERATIVE    SUBGEBY. 

may  not  require  to  be  secured.  The  largest  vessel  is  that 
opposite  the  lirst  interosseous  space. 

Vessels  similarly  placed  will  be  divided  in  the  dorsal  flap. 
Probably  none  will  require  attention  except  the  artery  (the 
first  dorsal  interosseous)  that  is  cut  opposite  the  gap  between 
the  first  and  second  metatarsal  bones. 

Comment. — This  is  a  very  useful  amputation  in  cases  of 
crush  of  the  toes,  and  in  hmited  gangrene  from  frost-bite,  etc. 
If  the  tissues  in  the  sole  are  damaged,  the  dorsal  and  plantar 
flaps  may  be  of  equal  size.  A  single  dorsal  flap  should  be 
avoided.  Pezerat  advised  three  flaps — one  from  the  dorsum, 
one  from  the  sole,  and  one  from  the  inner  margin  of  the 
foot. 

THE   AFTER-TREATMENT   OF   AMPUTATIONS   OF   THE   TOES. 

It  must  be  confessed  that  the  wounds  of  these  operations 
do  not  always  heal  so  kindly  as  may  be  expected,  and  often 
compare  unfavourably  with  like  wounds  in  the  hand.  In 
many  cases  this  is  due  to  the  fact  that  the  operation  is  an 
imperfect  one — a  mere  trimming  of  a  mangled  part — and  is 
the  outcome  of  a  desire  to  remove  as  little  tissue  as  possible. 

The  less  easy  circulation  of  the  part,  and  the  circumstance 
that  the  wound  is  less  conveniently  placed  for  drainage,  serve 
to  some  extent  to  explain  the  tardier  healing  when  compared 
with  operation  wounds  of  the  fingers. 

The  limb  should  be  kept  out  in  the  open  air,  for  reasons 
already  detailed  (page  69).  The  leg  should  be  a  little  raised 
upon  a  pillow,  and  the  patient  should  lie  so  that  the  foot  can 
rest  upon  one  or  other  side.  When  the  patient  lies  flat  on  the 
back,  the  toes  point  upwards,  drainage  is  rendered  almost  im- 
possible, and  every  facility  is  given  for  the  gravitation  of  the 
discharges  of  the  wound  into  the  depths  of  the  foot.  If  the 
flaps  have  been  so  carelessly  cut  as  to  involve  some  sloughing, 
if  the  tendon-sheaths  have  been  left  open,  if  the  wound  is 
loosely  dressed  and  exposed  to  the  vitiated  atmosphere  under 
the  bed-clothes,  and  if  the  foot  is  so  placed  that  proper  drain- 
age is  impossible,  it  is  no  matter  for  wonder  that  the  stump 
does  not  do  well,  and  that  deep-seated  suppuration  is  detected 
in  the  foot. 

All  tight  bandages  should  be  avoided. 


AMFUTATIGN   OF   TOES.  417 

As  the  skin  of  plantar  flaps  is  usually  thick  and  stiff, 
sutures  should  be  so  appHed  as  to  retain  a  good  hold  of  the 
parts.  They  should  not  be  removed  too  soon,  as  the  flap  may 
give  way.  SilkwoiTQ-giit  sutures  may  often  be  left  in  for  ten 
or  even  fourteen  days. 

Portions  of  divided  tendons  may  slough,  and  a  watch  should 
be  kept  for  signs  of  inflammation  along  the  lines  of  those 
tendons. 

The  smaller  amputations  require  no  drainage-tube.  In 
operations  upon  the  great  toe,  a  fine  tube,  or  a  tube  split  in 
halves,  may  be  retained  for  the  first  twenty-four  hours. 


B  B 


418 


CHAPTER    XXIII. 

Partial  Amputation  of  the  Foot. 

amputations  through  the  tarso-metatarsal  joints. 

These  operations  consist  in  tlie  removal  of  single  toes,  with 
their  respective  metatarsal  bones,  and  in  the  removal  of  the 
whole  of  the  metatarsus  by  Lisfranc's  and  Hey's  operations. 

The  amputation  of  a  single  toe,  together  with  the  whole  of 
its  metatarsal  bone,  is  an  operation  of  little  practical  utility. 
It  may  possibly  be  of  service  in  some  very  limited  and  rare 
forms  of  disease,  and  it  is  conceivable  that  it  may  be  called 
for  in  some  exceptional  accidents.  The  occasions,  however, 
must  be  peculiarly  uncommon.  The  great  toe  and  the  little 
toe  are  the  ones  most  likely  to  afford  material  for  this 
operation.  The  elaborate  procedures  described  by  French 
authors  for  the  disarticulation  of  the  second  or  the  third  or 
the  fourth  toe,  together  with  its  metatarsal  bone,  are  purely 
dead-house  operations.  To  the  student  the  performance  of 
these  disarticulations  is  of  service  as  affording  a  training  for 
the  more  ready  carrying  out  of  Lisfranc's  operation. 

Anatomical  Points. — The  following  account  is  derived  from 
Mr.  Henry  Morris's  valuable  work  on  "The  Anatomy  of  the 
Joints."  There  may  be  said  to  be  three  separate  joints 
between  the  tarsus  and  metatarsus.  First,  the  joint  between  the 
internal  cuneiform  bone  and  the  first  metatarsal ;  second,  that 
between  the  three  cuneiforms  and  the  second  and  third  meta- 
tarsals ;  and  third,  the  joint  between  the  cuboid  and  the  fourth 
and  fifth  metatarsal  bones.  Looked  at  as  a  whole,  the  union 
of  the  tarsus  Avith  the  metatarsus  is  very  uneven,  owing  to  the 
backward  projection  of  the  second,  fourth,  and  fifth  bones 
behind  the  line  of  the  third,  and  the  forward  position  of  the 
first,  which  articulates  with  the  inner  cuneiform  nearly  half  an 
inch  in  advance  of  the  second,  and  about  a  quarter  of  an  inch 


PARTIAL  AMPUTATION   OF  FOOT. 


419 


in  front  of  the  third  metatarsal  bone,  where  they  articulate  with 
the  middle  and  outer  cuneiforms  respectively.  The  second 
metatarsal  is  let  back  into  a  space  between  the  three  cuneiform 
bones.  The  three  outer  metatarsals  are  placed  pretty  evenly 
in  a  line  having  a  gentle  curve,  with  its  convexity  towards  the 
phalanges  (Fig.  106). 

The  Inner  Tarso- Metatarsal  Joint. — The  internal  cuneiform 
bone  presents  a  large,  nearly  flat,  kidney-shaped,  articular 
surface,  inclined  a  little  inwards.  Its 
long  axis  is  vertical,  and  measures  one 
inch.  Its  breadth  is  half  an  inch  (Fig. 
107).  The  facet  on  the  first  metatarsal 
is  of  the  same  general  shape.  This  bone 
is  connected  with  the  inner  cuneiform  by 
a  complete  capsule,  the  fibres  of  which 
are  very  thick  on  the  under  and  inner 
aspects.  Those  on  the  outer  side  pass 
from  behind  forwards  in  the  interval 
between  the  interosseous  ligaments 
which  connect  these  tw^o  bones  with  the 
second  metatarsal.  The  plantar  Hgamcnt 
is  by  far  the  strongest. 

The  Middle  Tar  so- Metatarsal  Joint 
— The   facets   on   the    middle   and 


-BONES  OF   FOOT. 


ex- 


Fig.  106. 

A  A,  Line  of  Lisfranc's  am- 
putation. 


ternal  cuneiforms  are  flat  and  triangular, 
with  their  bases  at  the  dorsum.  Each  measures  about  three- 
quarters  of  an  inch  vertically,  and  the  width  of  its  base  is 
about  half  an  inch  (Fig.  107).  Lateral  facets  on  the  inner  and 
outer  cuneiform  bones  articulate  with  like  facets  on  the  sides 
of  the  base  of  the  second  metatarsal.  The  posterior  facets  on 
the  second  and  third  metatarsals  correspond  in  size  and  shape 
with  those  on  the  two  middle  cuneiforms. 

The  ligaments  of  the  joints  are  the  following: — Dorsal: 
between  the  bases  of  the  two  metatarsals  and  the  three 
cuneiform  bones.  Plantar:  a  strong  ligament  between  the 
inner  cuneiform  and  the  second  and  third  metatarsals,  and 
slender  hgaments  between  the  middle  cuneiform  and  the 
second  metatarsal,  and  the  outer  cuneiform  and  the  third 
bone.  Interosseous :  the  middle  portion  of  the  tarso-meta- 
tarsal  joint  is  shut  off  from  the  inner  portion  by  a  very  strong 

B   B   2 


420 


OPERATIVE   SUBGEBY. 


M.-7 


interosseous  ligament  (the  ligament  of  Lisfranc),  which  extends 
between  the  outer  surface  of  the  tirst  cuneiform  and  the 
inner  surface  of  the  base  of  the  second  metatarsal.  A  second 
band  runs  from  the  external  cuneiform  to  the  third  and  fourth 
naetatarsak,  and  shuts  in  the  joint  on  its  outer  side. 

The  Cuho-TYietatarsal 
Joint. — The  cuboid  looks 
forwards  and  outwards,  and 
presents  two  unequal  facets, 
which  articulate  with  like 
facets  on  the  fourth  and  fifth 
metatarsal  bones  (Fig.  107). 
Dorsal  and  plantar  liga- 
ments pass  between  the 
cuboid  and  the  two  bones, 
while  the  interosseous  liga- 
ment just  named  shuts  off 
the  joint  on  its  inner  side. 

The  synovial  memhrane 
of  the  inner  articulation  is 
single,  and  separated  from 
all  the  other  tarso-metatarsal 
joints.  That  of  the  middle 
articulation  is  an  extension  forwards  from  the  synovial  mem- 
brane of  the  scapho-cuneiform  and  outer  cuneiform  articula- 
tions, while  the  synovial  membrane  of  the  cubo-inetatarsal 
joint  is  special  to  that  articulation  and  to  the  joint  between 
the  bases  of  the  fourth  and  fifth  metatarsal  bones. 

Each  metatarsal  bone  has  one  epiphysis,  which  is  placed 
at  the  distal  extremity  of  the  four  outer  bones  (and  forms 
the  head),  and  at  the  proximal  end  of  the  metatarsal  of  the 
great  toe,  of  which  it  forms  the  base.  The  epiphyses  join  the 
shafts  betAveen  eighteen  and  twenty. 

The  following  attachments  of  tendons  may  be  noted  : — To 
the  base  of  the  first  metatarsal  bone  the  peroneus  longus  and 
part  of  the  tibialis  anticus  ;  to  the  base  of  the  fifth  metatarsal 
the  peroneus  brevis  and  peroneus  tertius. 

The  communicating  branch  of  the  dorsalis  pedis  artery 
passes  between  the  bases  of  the  first  and  second  metatarsal 
bones.     The  plantar  arch  crosses  the  joint  between  the  fourth 


Fig.  107. — TEA:5fSVEESE  SECTION  OF  THE 
FOOT  AT  THE  TAESO-METATAESAL  LINE 
OF   JOINTS. 

0,  Cuboid;  I.e.,  M.C.,  E.G.,  The  three  cunei- 
form bones ;  1,  Ext.  prop,  pollicis  ;  2, 
Ext.  long,  digit. ;  3,  Ext.  brevis  digit.  ;  4, 
Peron.  tertius ;  5,  Peron.  brevis ;  6, 
Peron.  longus  ;  7,  Tibialis  ant.  ;  8,  Flex. 
long.  poU.  ;  9,  Flex.  long,  digit.  ;  10, 
Abduct,  min.  digit.  :  11,  Flex.  brev. 
digit.  ;  12,  Abduct,  hallucis. 


PARTIAL  AMPUTATION  OF  FOOT.  421 

and  fifth  metatarsals  obliquely,  and  rims  over  the  bases  of  the 
second  and  third  metatarsals  at  some  little  distance  from  the 
line  of  the  tarso- metatarsal  joints. 

Instruments. — A  stout  knife  with  a  blade  three  inches 
long-.  (For  the  flap  operation  upon  the  great  toe  a  more 
slender  knife,  -svith  a  blade  of  about  three  and  a  half  inches 
in  length.)  Narrow  metal  retractors.  Lion  forceps  (in  the 
event  of  the  part  being  crushed).  Dissecting,  pressure,  and 
artery  forceps. 

Pofiition. — The  same  as  for  previous  amputations.  {See 
page  404.) 

DISARTICULATION   OF   A   TOE,   TOGETHER   WITH    ITS   METATARSAL 

BONE. 

Disarticulation  of  the  Great  Toe,  together  with  its  Meta- 
tarsal Bone.— (a)  By  Oval  or  Racket  Incision. — Having 
defined  the  metatarso-tarsal  joint,  grasp  the  toe  with  the 
left  hand,  and  enter  the  knife  at  the  inner  border  of  the 
foot,  just  below  the  line  of  the  joint.  Carry  the  incision  out- 
wards, parallel  to  the  articulation  line,  until  the  centre  of  the 
dorsal  aspect  of  the  metatarsal  bone  is  reached  (Fig.  117,  a). 
Now  continue  the  cut  straight  down  towards  the  nail,  along 
the  median  line  of  the  dorsum  of  the  bone.  This  incision 
will  lie  to  the  inner  side  of  the  extensor  proprius  poUicis 
tendon.  On  reaching  the  centre  of  the  metatarsal  bone, 
incline  the  incision  to  the  web,  then  round  the  outer  side  of 
the  root  of  the  toe  (the  phalanx  being  turned  out),  and  so  on 
to  the  plantar  aspect.  Let  the  knife  cross  the  plantar  sur- 
face transversely  in  the  groove  that  separates  the  toe  from  the 
sole.  Finally,  curve  the  incision  round  the  outer  aspect  of 
the  toe  to  reach  the  dorsal  wound  at  the  centre  of  the  meta- 
tarsal bone.     The  incision  involves  the  skin  only. 

Now  deepen  the  dorsal  cut.  Divide  the  tendons  of  the  ex- 
tensor proprius  and  extensor  brevis  close  to  the  metatarso-tarsal 
joint.  Separate  the  soft  parts  from  the  inner  and  outer  sides  of 
the  bone,  keeping  close  to  it,  and  cutting  from  the  tarsus  to- 
wards the  toe.  While  effecting  this  separation  the  assistant 
turns  the  toe  to  one  or  other  side,  and  the  surgeon  uses  his  left 
fingers  to  draAV  away  the  soft  parts.  The  assistant  now  partty 
extends  the  toe,  and,  the  flexor  tendon  having  been  cut,  the 


4:i2  OPERATIVE    SURGERY. 

soft  parts  are  dissected  off  from  tlie  plantar  aspect  of  the 
bone.  The  bone  should  be  bared  back  to  the  joint.  The 
sesamoid  bones  are  left  behind. 

Care  must  be  taken  not  to  wound  the  communicating 
branch  of  the  dorsalis  pedis  artery  which  runs  between  the 
two  toes. 

The  next  step  is  to  open  the  joint  on  the  dorsal  aspect, 
and  as  far  as  possible  on  the  outer  and  inner  sides.  The 
surgeon  now  once  more  grasps  the  toe  and  divides  the  plantar 
and  remaining  ligaments.  Last  of  all,  the  tendons  of  the 
peroneus  longus  and  tibiahs  anticus  are  cut,  and  the  toe  Avith 
its  metatarsal  bone  is  free. 

Cut  the  flexor  tendon  short,  and  close  its  sheath  (page  322). 
If  the  transverse  cut  at  the  commencement  of  the  incision 
be  not  employed,  the  wound  niust  start  over  the  cuneiform 
bone. 

Hcemorrhage. — The  dorsal  digital  branches  (of  the  first 
interosseous  artery)  to  the  sides  of  the  toe  are  divided  in  the 
dorsal  incision.  The  inner  one  will  probably  need  no  atten- 
tion. In  the  plantar  aspect  of  the  wound  are  divided  the  ter- 
mination of  the  internal  plantar  artery,  the  first  plantar 
digital  artery,  and  the  internal  digital  branch  to  the  great 
toe.  There  is  great  risk  of  wounding  the  communicating 
branch  of  the  dorsalis  pedis  in  the  gap  between  the  first  and 
second  toes. 

(b)  By  the  Flap  Method. — Having  grasped  the  toe  with 
the  left  hand,  the  knife  is  entered  on  the  dorsum  of  the  foot 
over  the  proximal  end  of  the  metatarsal  bone.  The  incision 
is  carried  forward  on  the  dorsum  of  the  bone  until  its  head  is 
reached.  It  now  crosses  the  inner  side  of  the  toe  to  the 
plantar  aspect  of  the  foot,  and  thence  is  continued  back  to  a 
spot  immediately  below  the  point  of  commencement. 

Both  the  dorsal  and  plantar  incisions  may  be  made  by 
cutting  from  behind  forAvards,  and  then  joined  by  a  vertical 
incision  over  the  head  of  the  bone.  The  flap  thus  marked 
out  is  now  dissected  back.  In  doing  this  the  surgeon  draws 
back  the  divided  soft  parts  with  his  left  fingers  while  the 
assistant  holds  the  toe.  The  extensor  tendons  are  left  in  situ. 
The  flap  must  include  everything  down  to  the  bone.  When 
it  has  been  dissected  back  to  beyond  the  level  of  the  joint, 


PARTIAL  AMPUTATION  OF  FOOT.  423 

the  extensor  tendons  are  divided,  and  the  joint  opened  on 
its  dorsal  and  internal  aspects.  The  tendon  of  the  tibiahs 
anticus  is  divided  at  this  step. 

Now,  having  grasped  the  toe  in  the  left  hand,  the  surgeon 
thrusts  the  knife  between  the  bases  of  the  two  metatarsals, 
keeping  the  blade  very  close  to  the  inner  bone,  and  brings  the 
point  out  at  the  plantar  wound.  The  knife  is  then  made  to 
cut  its  way  out  between  the  two  toes.  The  soft  parts  are 
cleared  from  the  plantar  aspect  of  the  bone,  the  flexor  tendon 
is  divided  high  up,  and  finally,  the  hgamentous  structures  at 
the  outer  side  of  the  joint  having  been  divided,  together  with 
the  peroneus  longus,  the  toe  is  free.  The  sesamoid  bones  are 
removed  with  the  toe.     The  flexor  sheath  should  be  closed. 

HceTTiorrhage. — In  the  outer  surface  of  the  wound — the 
wound  left  by  the  transfixion  cut  between  the  toes — are  divided 
the  dorsal  digital  branches  to  both  sides  of  the  great  toe,  the 
internal  digital  branch  to  the  same  toe,  and  the  first  plantar 
digital  artery.  The  only  bleeding  point  in  the  flap  will 
belong  to  the  termination  of  the  internal  plantar  artery. 

The  first  dorsal  interosseous  artery  is  very  apt  to  be  cut, 
as  is  also  the  communicating  branch  from  the  dorsalis  pedis. 
In  clearing  the  soft  parts  it  is  most  important  to  keep  close  to 
the  bone. 

Comment — Of  these  two  operations,  the  first-named  is 
unquestionably  the  better.  The  flap  operation  involves  a 
large  wound  and  a  badly-placed  cicatrix  The  flap  is  thin, 
especially  on  its  dorsal  aspect,  and  is  very  poorly  supplied 
with  blood. 

Disarticulation  of  the  Little  Toe,  together  with  its  Meta- 
tarsal Bone,  by  the  Oval  or  Racket  Incision. — The  toe  being 
grasped  by  the  left  hand,  the  knife  is  entered  at  the  outer 
margin  of  the  foot  about  1  cm.  behind  the  tuberosity  of  the 
fifth  metatarsal  bone.  An  oblique  cut — parallel  with  the  cubo- 
metatarsal  joint^s  made  (Fig.  116,  a),  and  a  median  dorsal 
incision  is  carried  thence  to  the  neck  of  the  metatarsal  bone. 
Here  the  oval  is  made  just  as  in  the  disarticulation  of  the 
great  toe  (page  421).  The  subsequent  steps  of  the  operation 
are  practically  identical  with  those  already  described. 

The  outer  tendon  of  the  extensor  longus  digitorum  lies  to 
the   inner  side  of  the  wound,  and  is  divided  at  the  highest 


424  OPERATIVE    SUBGEBY. 

point  of  the  dorsal  incision.  At  this  point  also  some  portion 
of  the  fleshy  part  of  the  extensor  brevis  will  be  exposed. 

When  the  outer  and  inner  sides  of  the  bone  have  been 
cleared  of  soft  parts,  the  tendons  of  the  peroneus  tertius  and 
peroneiis  brevis  are  cut,  the  joint  between  the  cuboid  and 
tifth  metatarsal,  and  also  that  between  the  bases  of  the  fourth 
and  lifth  bones  are  opened  from  the  dorsum.  The  plantar 
surface  of  the  bone  is  then  cleared,  and  the  disarticulation  is 
completed  as  in  the  case  of  the  great  toe. 

To  the  base  of  the  bone  strong  processes  from  the  plantar 
fascia  are  attached,  and  require  division.  It  should  be  remem- 
bered that  a  double  articulation  is  opened  in  this  operation 
(page  420). 

Hcemorrhage. — In  the  dorsal  incision  the  dorsal  digital 
arteries  of  the  toe  are  divided,  while  the  plantar  digital 
vessels  are  found  cut  on  the  plantar  aspect  of  the  wound. 

Any  one  of  the  other  metatarsal  hones  may  be  removed, 
with  its  corresponding  toe,  by  the  oval  incision.  The  outer 
two  bones  may  in  like  manner  be  removed  together  by  the 
oval  operation,  the  queue  of  the  oval  running  along  the 
interosseous  space  between  the  two  bones. 

As  already  stated,  these  operations  are  of  little  practical 
value.     (For  the  after-treatment,  see  page  442.) 

LISFRANC'S   OPERATION. 

A  disarticulation  of  the  anterior  part  of  the  foot  at  the 
tarso-metatarsal  line,  useful  in  hmited  cases  of  bone  disease, 
of  frost-bite,  or  of  gangrene,  and  in  some  examples  of  perforating 
ulcer  of  the  foot.  (For  the  anatomy  of  the  line  of  joints,  see 
page  410,  and  Fig.  106.) 

Instruments. — A  strong,  stout,  narrow  knife,  about  four  or 
five  inches  long  in  the  blade  ;  a  scalpel ;  a  saw,  in  the  event  of 
the  joints  being  anchylosed  ;  a  narrow  metal  spatula  ;  pressure 
forceps,  artery  and  dissecting  forceps ;  lion  forceps  if  the  toes 
be  crushed. 

Position. — The  patient  lies  on  the  back.  The  foot  is 
drawn  well  beyond  the  end  of  the  table,  and  is  raised  upon 
a  support  until  on  a  level  with  the  surgeon's  neck.  The 
operator  may  stand  to  cut  the  dorsal  flap,  but  should  sit  at 
the  end  of  the  table  facing  the  patient,  to  cut  the  sole  flap 


LISFBANO'-S  AMPUTATION.  425 

and  complete  the  disarticulation.  The  assistants  stand  one 
on  each  side  of  the  end  of  the  table. 

Operation  (Right  Foot). — 1.  The  Dorsal  Flap. — Grasp  the 
extended  foot  with  the  left  hand,  so  that  the  thumb  is  on  the 
base  of  the  lifth  metatarsal  bone  and  the  forefinger  on  that  of 
the  first,  while  the  palm  of  the  hand  faces  the  sole.  The 
skin  on  the  dorsum  is  stretched,  and  the  knife  is  held  in  the 
free  hand,  with  the  forefinger  on  the  back  of  the  blade.  In 
this  position  the  dorsal  flap  is  cut.  The  incision  commences 
at  the  outer  margin  of  the  foot,  just  behind  the  tubercle  of 
the  fifth  metatarsal  bone  (Fig.  108).  For  about  an  inch  it 
follows  the  outer  border  of  the  bone.  It  then  sweeps  across 
the  dorsum  parallel  to  the  line  of  the  tarso-metatarsal  joints, 
and  about  half  an  inch  in  front  of  it.  The  cut  is  curved 
towards  the  toes,  and  reaches  the  plantar  aspect  of  the  inner 
border  of  the  foot  about  half  an  inch  in  front  of  the  tarsal 
joint  of  the  great  toe.  It  finally  follows  the  inner  margin  of  the 
foot,  and  ends  three-fourths  of  an  inch  behind  the  said  joint. 

The  assistant  now  holds  the  foot  fixed  in  the  extended 
position  while  the  surgeon  uses  his  left  fingers  to  dissect  back 
the  dorsal  flap.  The  dissection  at  first  includes  the  skin  only ; 
but  when  the  integument  has  been  retracted  about  one-fourth 
of  an  inch,  the  extensor  tendons  are  divided.  The  flap  contains 
therefore  all  the  soft  parts  down  to  the  bones.  It  is  important 
to  well  expose  the  metatarsus,  and  to  carry  the  flap  back  far 
enough  to  expose  the  tarso-metatarsal  joint-line.  {See  the 
Comment  upon  the  operation,  page  428.) 

2.  The  Plantar  Flap. — The  plantar  flap  is  now  cut.  The 
surgfeon  flexes  the  foot  with  the  left  hand,  his  thumb  being 
along  the  line  of  the  toes,  and  his  fingers  on  the  dorsum. 
The  knife  is  introduced  at  right  angles  to  the  surface  of  the 
now  well-exposed  sole.  The  incision,  commencing  on  the 
outer  side,  follows  the  plantar  edge  of  the  fifth  metatarsal  for 
a  short  distance,  and  then  sweeps  obliquely  across  the  sole  to 
the  neck  of  the  fourth  metatarsal.  It  now  traverses  the  sole 
just  behind  the  line  of  the  heads  of  the  metatarsus,  and 
finally  follows  the  plantar  edge  of  the  metatarsal  bone  of  the 
great  toe  to  join  the  extremity  of  the  dorsal  incision.  The 
plantar  flap  is  thus  convex  forwards,  and  the  inner  segment 
is  longer  than  the  outer  (Figs.  108  and  118,  a). 


426 


OPERATIVE    SURGERY. 


The  incision  at  first  involves  the  skin  and  the  subcu- 
taneous tissues  only.  The  assistant  now  grasps  the  toes  and 
keeps  them  fully  extended  while  the  surgeon  dissects  back 
the  flap.  This  should  include  the  subcutaneous  structures 
only  until  the  hollow  behind  the  heads  of  the  metatarsal 
bones  is  reached.  When  this  hollow 
is  exposed,  the  tightly-stretched  flexor 
tendons  are  divided  by  a  vigorous 
transverse  cut.  The  rest  of  the  flap 
includes  all  the  soft  parts  down  to  the 
bones.  These  are  dissected  uj)  by 
short  transverse  cuts  with  the  knife 
while  the  operator  pulls  back  the  flap. 
The  separation  is  carried  back  until 
the  line  of  the  tarso-metatarsal  articu- 
lations is  reached.  The  exposure  of  the 
peroneus  longus  tendon  will  indicate 
when  this  line  is  reached.  The  tendon 
should  for  the  present  be  left  uncut. 

3.  The  Disarticulation. — Return  to 
the  dorsum.  Grasp  the  foot  Avith  the 
left  hand  and  extend  it  fully.  Let  an 
assistant  hold  back  the  dorsal  flap  with 
one  hand  while  by  means  of  a  metal 
spatula  he  retracts  and  protects  the 
plantar  flap  with  the  other.  Enter 
the  knife  just  behind  the  tubercle  of  the 
fifth  metatarsal  bone,  and,  cutting  obliquely  forwards  and 
inwards,  open  the  tarsal  joints  of  the  three  outer  metatarsal 
bones.  In  this  manoeuvre  the  tendons  of  the  peronei  brevis 
and  tertius  are  divided.  Now  turn  to  the  inner  side  of  the 
foot,  and  open  the  joint  between  the  first  metatarsal  and  the 
inner  cuneiform,  cutting  at  the  same  time  the  tibialis  anticus 
expansion.  In  the  next  place,  open  the  joint  between  the 
second  metatarsal  and  the  middle  cuneiform  on  its  dorsal  aspect. 
The  complete  separation  of  the  metatarsal  bone  is  difficult, 
and  is  thus  effected :  Hold  the  knife  like  a  trocar  and — keep- 
ing it  nearly  parallel  with  the  dorsum  of  the  foot — thrust  the 
point  in  deeply  between  the  bases  of  the  first  and  second 
metatarsal    bones   (Fig.    109)   until    it  is   arrested   b}*   bone. 


108. — LISFRANC'S 
PUTATION. 


LISFBANC'S  AMPUTATION. 


427 


The  edge  is  turned  towards  the  ankle.  Now  grasp  the  knife 
in  the  hand  like  a  dagger,  and  elevate  the  handle  until  it  is 
perjDendicular  to  the  dorsum  of  the  foot,  at  the  same  time 
cutting  in  the  direction  of  the  external  malleolus  (Fig.  110). 
By  this  manoeuvre  (the  coup  de  maitre)  the  strong  ligament  of 
Lisfranc  (page  420)  is  severed. 


Fig.  109.— THE   COITP  DE   MA.ITEE    IN  LISFEANC'S  AMPUTATION  :     FIEST   STEP. 

{After  Guerin.) 

Divide  any  remaining  ligaments,  especially  those  on  the 
plantar  aspect  of  the  joints,  and  finally  the  metatarsus  is  left 
attached  only  by  means  of  the  peroneus  longus  tendon.  Draw 
this  tendon  out,  and  cut  it  at  the  outer  angle  of  the  incision 
and  the  parts  to  be  removed  are  free. 


Fig 


no. — THE   COTTP  DE   MAITEE   IN  LISFEANC'S  AMPUTATION: 

{After  Guerin.) 


SECOND   STEP. 


Left  Foot. — Commence  the  dorsal  and  plantar  mcisions  on 
the  inner  side  of  the  foot.     In  disarticulatuig,  open  first  the 


428  OPERATIVE    SUBGEBY. 

joint  between  the  metatarsal  bone  of  tbe  great  toe  and  the 
inner  cuneiform,  then  open  the  tarsal  joints  of  the  three  outer 
metatarsals,  and  finally  disarticulate  the  second  metatarsal. 

Hcemorrhage. — In  the  dorsal  flap  are  divided  the  dorsal 
interosseous  arteries  (four),  opposite  to  the  interosseous  spaces, 
and  the  plantar  branch  of  the  dorsahs  pedis  as  it  dips  down 
between  the  bases  of  the  first  two  metatarsal  bones.  In  the 
plantar  flap  are  divided  the  plantar  digital  branches  of  the 
external  plantar,  and  probably  that  vessel  itself,  near  the  base 
of  the  second  metatarsal.  The  terminal  part  of  the  internal 
plantar  artery  is  also  divided. 

Comment — The  dorsal  flap  having  been  made,  the  dis- 
articulation may  be  at  once  proceeded  with,  and  the  operation 
completed  b}''  cutting  the  plantar  flap  from  within  outwards — 
i.e.,  practically  by  transfixion.  Or  the  disarticulation  having 
been  effected  from  the  dorsum,  the  plantar  flap  may  be  subse- 
quently cut  in  the  manner  already  described.  On  the  other 
hand,  the  operation  may  be  commenced  by  cutting  the  plantar 
flap,  and  then  be  completed  by  the  making  of  the  dorsal  flap 
and  disarticulation. 

These  various  modifications,  together  with  the  procedure 
described  at  length,  are  all  known  generally  by  the  term 
"  Lisfranc's  operation." 

The  stump  resulting  from  this  amputation  is  well  formed 
and  useful. 

The  following  pomts  may  be  observed  in  the  performance 
of  the  operation  : — 

It  is  a  common  fault  to  make  the  dorsal  flap  too  small,  and 
to  limit  it  strictly  to  the  dorsum.  This  flap  should  include 
not  only  the  dorsal  structures,  but  also  the  greater  part  of 
those  of  the  outer  and  inner  margins  of  the  foot.  The  relative 
sizes  of  the  two  flaps  may  be  estimated  by  noting  the  measure- 
ment of  hah'  the  circumference  of  the  foot  at  the  amputation- 
Une.  An  unduly  large  plantar  flap  forms  an  unwieldy  pocket. 
If  the  dorsal  incision  be  carried  too  far  back,  the  joint  be- 
tween the  scaphoid  and  cuneiform  bones  may  be  opened  by 
mistake  on  the  inner  margin  of  the  foot. 

In  dissecting  back  the  dorsal  flap  the  knife  should  be  kept 
close  to  the  bones,  and  care  must  be  taken  not  to  damage 
the  interosseous  vessels  that  run  in  the  flap.     In  this  flap 


EETS  AMPUTATION.  429 

portions  of  the  interossei  muscles  will  be  found,  and  especially 
some  fibres  of  the  first  dorsal  interosseous.  The  line  of  the 
articulations  must  be  well  exposed. 

In  disarticulating,  care  must  be  taken  not  to  damage  the 
plantar  flap.  During  the  separation  of  the  second  metatarsal 
from  the  tarsus,  I  have  seen  the  foot  so  vigorously  extended 
that  the  bone  has  been  fractured  through  its  base,  and  much 
difficulty  has  been  experienced  in  removing  the  fragment  thus 
left  behind. 

hey's  operation. 

This  operation  resembles  Lisfranc's  procedure  in  all  essential 
points,  and  differs  only  in  this — the  four  outer  metatarsal  bones 
are  disarticulated  from  the  tarsus,  and  the  projecting  end  of 
the  internal  cuneiform  bone  is  sawn  through,  carrying  the 
first  metatarsal  bone  with  it.  As  "  Hey's  operation  "  has  been 
variously  described,  I  give  here  the  original  description  : — 

"  In  the  year  1799  I  had  the  opportunity  of  repeating  this 
operation"  (resection  of  the  front  of  the  foot),  "  and  found  it  to 
answer  perfectly  my  expectations.  I  made  a  mark  across  the 
upper  part  of  the  foot,  to  point  out  as  exactly  as  I  could  the 
place  where  the  metatarsal  bones  were  joined  to  those  of  the 
tarsus.  About  half  an  inch  nearer  the  toes  I  made  a  trans- 
verse incision  through  the  integuments  and  muscles  covering 
the  metatarsal  bones.  From  each  extremity  of  this  wound  I 
made  an  incision  (along  the  inner  and  outer  sides  of  the  foot) 
to  the  toes.  I  removed  all  the  toes  at  their  junction  with  the 
metatarsal  bones,  and  then  separated  the  integuments  and 
muscles  forming  the  sole  of  the  foot  from  the  inferior  part  of 
the  metatarsal  bones.  .  .  I  then  separated  with  the  scalpel 
the  four  smaller  metatarsal  bones  at  their  junction  with  the 
tarsus,  which  was  easily  effected,  as  the  joints  lie  in  a  straight 
line  across  the  foot.  The  projecting  part  of  the  first  cuneiform 
bone,  which  supports  the  great  toe,  I  was  obliged  to  divide 
with  a  saw." 

Hey  himself  appears  to  have  been  a  little  indefinite  about 
the  procedure  that  bears  his  name,  for  in  one  of  the  instances 
he  dissected  out  all  the  metatarsal  bones,  and  in  another  he 
drew  the  saw  across  the  bases  of  those  bones. 

A  modification  of  this  operation,  practised   by  the  late 


430  OPERATIVE    SURGERY. 

Prof.  R.  W.  Smith,  is  tlius  described  by  Sir  William  Stokes. 
It  is  claimed  as  an  advantage  tliat  the  two  anterior  points  of 
support — viz.,  the  ball  of  the  great  toe  and  the  base  of  the 
fifth  metatarsal  bone — are  preserved. 

"  The  operation  is  performed  by  making  an  oblique  incision 
across  the  four  lesser  metatarsal  bones,  commencing  about  three- 
fourths  of  an  inch  in  front  of  the  base  of  the  fifth  metatarsal  bone, 
and  in  a  direction  towards  the  metatarso-phalangeal  articulation 
of  the  great  toe.  The  incision  should  be  made  down  to  the 
bones,  and  another  incision  should  then  be  made  at  the  centre 
of  the  first  one,  but  at  right  angles  to  it,  upwards  and  inwards, 
for  about  an  inch  or  an  inch  and  a  quarter.  The  tissues  at 
each  side  of  the  second  incision  should  then  be  dissected  off 
the  bones,  and  these,  thus  freely  exposed,  should  be  obliquely 
divided  close  to  their  proximal  articulations  with  a  small  saw 
or  fine  forceps.  The  flap  should  be  taken  altogether  from  the 
sole  of  the  foot "  (Heath's  "  Dictionary  of  Surgery,"  voL  i., 
page  551). 

For  the  after-treatment  of  these  operations,  see  page  442. 


431 


CHAPTER    XXIV. 
Partial  Amputation  of  the  Foot. 


AMPUTATION    THROUGH   THE    MEDIO-TARSAL    JOINT    (CHOPART's 

operation). 

This  consists  of  a  disarticulation  of  the  foot  at  the  medio- 
tarsal  jomt.  The  procedure  that  at  the  present  day  is  known 
by  this  name  differs  someAvhat  in  detail  from  the  operation  as 
originally  described  by  Chopart. 

Anatomical  Points. — The  medio-tarsal  joint  consists  of 
two  articulations — the  calcaneo-cuboid  on  the  outer  side,  and 
the  astragalo  -  scaphoid  on  the  inner. 
These  two  joints  have  distinct  synovial 
membranes.  They  lie  nearly  in  a  trans- 
verse line,  but  the  astragalo-scaphoid 
joint  is  more  convex  anteriorly,  and  is  a 
little  in  advance  of  the  companion  articu- 
lation. The  first-named  articulation  forms 
a  ball-and-socket  joint,  the  convex  head 
of  the  astragalus  being  secured  in  the 
concave  facet  of  the  scaphoid  (Fig.  111). 
The  greatest  vertical  measurement  of  the 
articulation  is  one  inch,  while  its  greatest 
transverse  measurement  is  about  the  same. 
The  following  ligaments  support  the  joint : 
■ — (1)  The  astragalo-scaphoid,  a  thin  dorsal 
ligament;  (2)  the  inferior  calcaneo-scaphoid,  a  dense,  thick 
fibrous  plate,  that  lies  just  under  the  joint ;  (3)  the  external 
calcaneo-scaphoid.  This  band  lies  in  the  hollow  between  the 
two  joints  of  the  medio-tarsal  line.  It  starts  from  the  os  calcis, 
and  blends  above  and  below  with  the  two  ligaments  already 
named.  It  is  called  by  the  French  the  Y  ligament,  "  la  clef 
de  I'articulation   de   Chopart."     The   synovial   -niembrane    of 


111. — BONES      OP 
THE   FOOT. 

A  A,  Line  of  Chopart's 
Amputation. 


432 


OPERATIVE    SURGERY. 


tliis  joint  is  conunon  also  to  the  anterior  astragalo-calcaneal 
articulation. 

The  calcaneo-cuboid  joint  presents  a  concavo-convex  surface 
the  concavity  inchning  from  above  downwards  and  inwards. 
It  measures  about  three-quarters  of  an  inch  vertically,  and  one 
inch  transversely.  It  is  supported  by  the  following  ligaments: — 
(1)  The  internal  calcaneo-cuboid,  a  strong  band  ;  (2)  the  dorsal 
calcaneo-cuboid,  a  wider  Hgament ;  and 
(3)  and  (4),  the  well-known  long  and 
short  plantar  Hgaments.  The  sjmovial 
membrane  is  pecuHar  to  the  joint.  This 
articulation  lies  on  a  Hne  midway  between 
the  tip  of  the  external  malleolus  and 
the  tuberosity  of  the  fifth  metatarsal 
bone.  The  companion  joint  will  be 
found  just  behind  the  tuberosity  of  the 
scaphoid — a  conspicuous  landmark. 

Instruments  and  Position.  —  The 
same  as  for  Lisfranc's  operation.  The 
surgeon  should  sit  to  cut  the  plantar 
flap,  but  will  find  it  more  convenient  to 
stand  while  cutting  the  dorsal  flap  and 
while  disarticulatmg. 

Operation. — In  its  main  points  the 
procedure  is  identical  with  Lisfranc's 
amputation.  1.  The  dorsal  flap. — The 
incision  commences  at  a  point  midway  between  the  tip  of  the 
outer  malleolus  and  the  tuberosity  of  the  fifth  metatarsal  on 
the  outer  side,  and  at  a  point  just  behind  the  tuberosity  of  the 
scaphoid  on  the  inner  side.  The  cut  foUows  on  either  side  the 
margin  of  the  foot  for  a  Httle  distance,  and  is  then  so  curved 
over  the  dorsum  as  to  cross  the  bases  of  the  metatarsal  bones 
(Fig.  112).  2.  The  plantar  flap  extends  between  the  two 
points  first  named.  It  follows  in  the  main  the  lines  of  Lis- 
franc's flap,  and  has  the  same  shape.  It  is  so  carried  over 
the  sole  as  to  cross  the  middle  of  the  metatarsus  (Figs. 
112  and  118,  b).  The  flexor  tendons  are  divided  as  soon  as  a 
little  skin  has  been  retracted.  Both  flaps  contain  all  the  soft 
parts  down  to  the  bones.  The  medio-tarsal  joint-line  should 
be  well  exposed. 


Fig.  112. — cnoPART's  am 

PUTATION. 


CHOP  ARTS  AMPUTATION. 


433 


3.  Tlie  Disarticulation. — In  disarticulating,  the  foot  may 
be  conveniently  held  in  the  position  of  talipes  varus,  and 
be  well  extended.  Care  must  be  taken  to  open  the  right 
joints.  It  is  easy  to  open  the  scapho-cuneiform  joints  in  the 
place  of  the  astragalo-scaphoid,  and  to  actually  leave  the 
scaphoid  behind. 

The  tendons  that  are  especially  to  be  noted  in  cutting  tho 
deeper  parts  are  the  three  peronei  and  the  two  tibials. 

Hcemorrhage. — In  the  dorsal  flap,  the  dorsalis  pedis  artery 
is  cut  as  it  dips  down  between  the  first  and  second  metatarsal 
bones.  The  metatarsal  and  tarsal  branches  of  that  vessel 
are  also  divided.  The  two  saphenous  veins  come  in  this 
flap. 

At  the  anterior  part  of  the  inner   segment  of  the  plantar 
flap  the  internal  plantar  artery  is  divided,  and  near  the  base 
of  the  second  metatarsal  bone  the  end  of 
the  external  plantar.     In  the  outer  part 
of  the  flap  are  the  digital  branches  of  the 
latter  vessel. 

Comment. — The  value  of  this  opera- 
tion is  open  to  serious  question,  and  in 
many  points  it  does  not  compare  favour- 
ably with  Syme's  amputation.  It  is  not 
adapted  for  cases  of  bone-disease  as  a 
rule.  The  stump  may  appear  an  excel- 
lent one  immediately  after  the  operation. 
In  process  of  time,  however,  it  will  be 
found  that  the  whole  of  the  os  calcis — 
iind  not  the  tuberosities  merely  —  is 
brought  in  contact  with  the  ground,  and 
that  the  somewhat  sharp-edged  anterior  part  of  the  bone  is 
not  well  suited  to  bear  pressure. 

In  some  cases  the  stump  has  a  tendency  to  turn  over  into 
what  would  be  the  varus  position,  and  the  patient  walks  upon 
the  outer  border  of  the  under  surface  of  the  os  calcis. 

In  other  instances — and  these  are  not  uncommon — the  heel 
IS  drawn  up  by  the  action  of  the  tendo  Achillis,  the  head  of  the 
■OS  calcis  is  tilted  do^ni wards,  and  upon  this  point  of  bone  the 
TDatient  walks  (Fig.  113).  A  stump  so  deformed  Anil  be  painful, 
and  will  probably  become  too  tender  to  bear  the  weight  of  the 


Fig.  llo. — ANATOMY  OF 
THE  STUMP  AFTKR 
CHOPAET'S  AMPUTA- 
TION.    {Farabei(f.) 


434  OPEIIATIVE    SURGERY. 

body :  or  the  cicatrix,  being  exposed  to  pressure,  may  break 
down. 

Attempts  have  been  made  to  prevent  this  mal-position  by 
attachmg  the  anterior  tendons,  inchiding  especially  the  tibiahs 
anticiis,  by  stout  sutures,  to  the  tissues  of  the  sole-flap. 

It  has  been  further  recommended  that  a  wedge-shaped  pad 
be  worn  in  the  boot,  so  placed  as  to  resist  the  turning- down  of 
the  head  of  the  os  calcis.  Finally,  the  tendo  Achillis  has  been 
divided.  This  tenotomy,  while  it  has  weakened  the  foot 
gi-eatly,  has  not  always  sufiiced  for  the  permanent  cure  of  the 
deformity.  (See  Tripier's  Operation,  page  453.)  In  some 
cases  caries  of  the  os  calcis  appears  to  have  supervened. 

The  planning  of  the  fl.aps  may  be  varied.  If  the  dorsal 
flap  be  curtailed,  the  plantar  flap  must  be  increased  in  length. 
Some  .surgeons,  hi?,ving  made  the  dorsal  flap,  and  effected  the 
disarticulation,  cut  the  plantar  flap  by  transfixion.  Such  a 
flap,  however,  is  apt  to  be  ill-shaped  and  thin,  and  the  plantar 
arteries  will  be  probably  divided  unnecessarily  high. 

It  has  been  advised  to  leave  the  scaphoid  bone  Avhen  sound, 
and  so  to  retain  the  attachment  of  the  tibialis  posticus.  To 
effect  this  end  the  flaps  must  be  cut  longer  on  the  inner  side. 
It  has  not  been  shoAvn  that  this  modification  is  of  special  value. 
( For  the  after-treatment,  see  page  442.) 


4^ 


CHAPTER    XXV. 
Partial   Amputation   of  the  Foot. 

subastragaloid  disarticulation. 

Tjits  operation  consists  of  a  disarticulation  at  the  astragalo- 
scaplioid  and  astragalo-calcaneal  joints.  The  astragakis  is  the 
only  bone  of  the  foot  that  is  left  behind,  and  forms  the  summit 
of  the  stnnip. 

Anatomical  Points. — The  astragalo-scaphoid  joint  has 
been  described  (page  431).     {See  also  Fig.  111.) 

The  OS  calcis  articulates  Avith  the  astragalus  by  a  double 
joint ;  the  anterior  communicates  with  the  medio-tarsal  artic- 
ulation ;  the  posterior  is  separate  and  complete  in  itself 
The  two  bones  each  present  two  articular  facets  of  unequal 
size,  separated  by  a  deep  groove,  in  which  is  lodged  the  inter- 
osseous ligament.  This  groove  and  ligament  divide  the 
anterior  from  the  posterior  joint.  In  front  of  the  inner  end 
of  the  groove  the  prominent  process — the  sustentaculum  tali 
— projects  inwardly.  The  posterior  facet  is  the  larger,  is  con- 
vex on  the  OS  calcis,  concave  on  the  astragalus,  and  is  about 
one  inch  and  a  half  in  length,  and  three-quarters  of  an  inch 
in  width.  The  anterior  facet  is  narrower,  smaller,  and  more 
internal.  It  is  concave  on  the  os  calcis,  and  runs  on  to  the 
upper  surface  of  the  sustentaculum  tali,  while  it  is  convex  on 
the  astragalus. 

The  under-surface  of  the  astragalus,  as  seen  after  the 
disarticulation,  is,  speaking  generally,  flat,  and  forms  an  even 
surface  for  the  end  of  the  stump.  The  groove  between  the 
facets  runs  obliquely  from  within  forwards  and  outwards. 

The  following  are  the  ligaments  between  the  os  calcis  and 
astragalus.  The  main  connection  is  effected  by  the  very 
massive  interosseous  ligament  which  occupies  the  whole 
length  of  the  groove.  On  the  outer  side  are  the  membranous 
external  calcaneo-astragaloid  and  external  ealcaneo-scaphoid 
c  c  '2 


436  OPERATIVE    SUBGEBY. 

ligaments,  and  a  part  of  the  external  lateral  ligament  of  the 
ankle.  Behind  is  the  posterior  calcaneo-astragaloid  ligament, 
and  on  the  inner  side  the  internal  ligament  of  that  name,  to- 
gether with  part  of  the  internal  lateral  ligament  of  the  ankle. 

Position  and  Instruments. — The  same  as  in  the  preced- 
ing operation. 

The  following  methods  ^\'ill  be  described : — 

1.  Farabeufs  operation. 

2.  The  oval  operation. 

3.  Verneuil's  operation. 

4.  By  the  heel  flap. 

1.  Farabeufs  Operation  by  a  Large  Internal  and  Plantar 
Flap. 

In  this  procedure  a  large  flap  is  cut  from  the  sole  and  the 
inner  aspect  of  the  foot. 

(1)  The  Line  of  Incision. — The  incision  is  commenced  at  the 
outer  margin  of  the  tendo  Achillis  at  its  insertion  (Fig.  114,  a), 
and  is  then  curved  up  a  little  to  reach  the  level  of  a  point  one 
inch  below  the  outer  malleolus.  It  is  now  carried  forwards 
horizontally,  parallel  to  the  outer  border  of  the  foot,  and  one 
inch  below  the  malleolus  (a  to  b),  and  reaches  a  point  (b) 
which  is  on  a  Hne  connecting  the  base  of  the  fifth  metatarsal 
bone  with  the  joints  between  the  scaphoid  and  .  cuneiform 
bones.  It  then  curves  sharply  inwards  across  the  dorsum  of 
the  foot  (b  to  x),  a  little  in  front  of  the  joints  named,  and 
reaches  the  extensor  proprius  polhcis  tendon  at  x.  The 
incision  next  crosses  the  inner  border  of  the  foot  so  as  to  follow 
the  line  of  the  cuneo-metatarsal  joint  of  the  great  toe  (x  to  c). 

It  now  sweeps  across  the  centre  of  the  sole  of  the  foot  (c 
to  d),  and  is  then  rounded  off  and  curved  back,  so  as  to  follow 
exactly  the  outer  border  of  the  foot  as  far  as  the  external 
tuberosity  of  the  os  calcis  (e).  It  is  now  curved  up  a  little  to 
end  at  the  insertion  of  the  tendo  Achillis  at  A.  {See  also 
Fig.  118,  E  and  Fig.  121,  a.) 

The  foot  must  be  turned  from  side  to  side  by  the  surgeon's 
left  hand  as  the  devious  line  of  this  incision  is  followed.  The 
knife  at  first  divides  only  the  skin  and  the  subcutaneous  tissue. 
It  is  then  made  to  follow  the  incision  a  second  time — when 
the  skin  has  retracted  a  little — and  is  carried  to  the  bone. 
Care  must  be  taken  that  the  knife  goes  well  down  to  the  bone, 


S UBASTRAGALOIB   AMFUTA TIOX. 


437 


and  that  all  the  soft  parts  are  divided.  To  effect  this  the 
blade  must  be  used  with  considerable  vigour.  The  border  or 
surface  of  the  foot  that  is  attached  must  be  put  upon  the  stretch, 
so  that  the  tendons  are  cleanly  divided.  The  peronei  tendons 
are  especially  difficult  to  cut.  In  making  these  deep  sweeps 
with  the  knife  great  care  must  be  taken  to  avoid  opening  any 


Fig.    114.  —  INNER   AND   OUTER   SIDES   OF  THE    EIGHT    FOOT,     TO    SHOW    THE   INCISIONS 
IN   FARABEUF'S   SUBASTRAGALOID    AMPUTATION. 

V,  The  lines  of  Verneuil's  siibastragaloid  amputation.    (For  other  references,  see  Text.) 


joints,  notably  tliose  between  the  scaphoid  ;;nd  the  cunei- 
form bones, 

(2)  The  Disarticulation. — The  leg  having  been  flexed  upon 
the  thigh,  the  assistant  turns  the  knee  in  with  one  hand  and 
presses  the  lower  part  of  the  leg  against  the  edge  of  the  couch 
with  the  other. 

The  foot  projects  beyond  the  end  of  the  table,  with  its 
outer  surface  well  exposed  and  lying  horizontally. 

Let  the  dorsal  part  of  the  flap  (x  to  a)  be  now  dissected 
up   sufficiently   to   well  expose  the   head    of  the  astragalus ; 


436  OPERATIVE    SURGERY. 

divide  the  tendo  Acliillis ;  open  tlie  astragalo-scaphoid  joint 
on  its  dorsal  aspect.  Keep  the  knife  between  the  bones,  and, 
rutting  backwards,  pass  it  between  the  os  calcis  and  astragakis, 
and  so  sever  the  interosseous  Hganicnt.  This  entails  no 
difficulty  if  the  outer  surface  of  the  foot  be  well  exposed  and 
kept  upon  the  stretch  with  the  left  hand.  As  the  liga- 
ment is  divided,  turn  the  os  calcis  more  and  more  out.  See 
that  all  the  tendons,  etc.,  are  divided  on  the  outer  side  of  the 
foot,  and  that  the  outer  aspect  of  the  os  calcis  is  bared  to  the 
periosteum. 

Now  with  the  left  hand  twist  the  foot  round  until  it 
is  in  the  position  of  the  extremest  varus.  In  this  position 
dissect — by  cuts  made  from  left  to  right  in  the  left  foot,  and 
from  right  to  left  in  the  right  foot — all  the  soft  parts  from  the 
mner  and  under  surfaces  of  the  os  calcis  (Fig.  115).  Special 
care  must  be  taken  of  the  vessels  which  lie  in  the  hollow  on 
the  inner  side  of  that  bone. 

.  Clear  the  under  surfixce  of  the  bone,  still  turning  the  foot 
out.  When  this  process  of  enucleation  is  complete,  the  foot 
will  have  been  so  turned  round  that  the  dorsum  will  face 
downwards.  Now  separate  the  foot  and  cut  anj^  neglected 
tendons  short. 

The  suture  line  on  the  stump  is  horizontal,  and  is  on  the 
outer  side  of  the  extreinit}^ 

The  operation  is  nmch  easier  on  the  left  than  on  the  right 
foot.  In  the  latter  case  it  may  be  more  convenient  to  dissect 
up  the  great  flap  and  bare  the  os  calcis  before  the  disarticula- 
tion is  effected. 

A  hole  may  be  made  in  the  heel  part  of  the  flap — which 
forms  a  pouch — and  a  drainage-tube  passed  through  it. 

Hcenwrrhage. — In  the  part  of  the  flap  a  to  B  are  cut  the 
posterior  peroneal,  the  anterior  peroneal,  and  branches  of  the 
tarsal  and  metatarsal  arteries.  The  largest  of  these  is  the 
first-named,  which  runs  just  behind  the  malleolus. 

In  the  part  b  to  x  the  tarsal  artery  and  the  dorsalis 
pedis — the  latter  a  large  vessel — are  divided  opposite  the 
centre  of  the  heac^  of  the  astragalus.  In  the  part  x  to  D 
the  internal  and  external  plantar  are  cut.  In  the  margin  of 
the  flap  D  to  E  branches  of  the  latter  vessel  are  found. 

2.  The  Oval  Operation  (Maurice  Perrin). — The  incision  in 


SUBASTBAGALOID   AMPUTATION. 


439 


this  procedure  commences  behind,  at  the  insertion  of  the 
tendo  Achillis,  and  is  carried  forwards  along  the  outer  side  of 
the  foot — parallel  with  its  external  border,  and  one  inch 
and  a  half  below  the  external  malleolus — to  a  point  just 
behind  the  base  of  the  fifth  metatarsal  bone. 

It  is   then   curved    across  the  dorsum  to   reach  on   the 


r^«*'"«|s»»sv* 


Fig.    115. — SUBASTEAGAIXJID   AMPUTATION  OF   THE  LEFT   FOOT.       {After  Furabeilf.) 


inner  side  of  the  foot  the  level  of  the  joint  between  the  first 
metatarsal  bone  and  the  cuneiform.  The  incision  now  sweeps 
back  across  the  sole  and  joins  the  first  cut  some  two  inches 
behind  the  base  of  the  fifth  metatarsal  bone  (Fig.  116,  b). 

The  incision  ma}'  at  first  involve  the  skin  onl}^  but  u.us 
then  be  carried  well  to  the  bone. 

The  subsequent  steps  of  the  operation  are  precisely  the 
same  as  in  the  previous  amputation.  The  foot  should  be 
placed  in  the  same  posture,  and  the  disarticulation  efi'ected  in 
the  same  manner. 


440 


OPERATIVE    SURGERY. 


It  is  advisable  to  saw  off  the  head  of  the  astragakis. 

In  the  left  foot  the  disarticulation  may  be  carried  out  as 
soon  as  the  dorsal  and  external  parts  of  the  flap  have  been 
dissected  back.  In  the  right  foot  the  whole  of  the  flap  had 
better  be  dissected  back  as  far  as  possible,  and  the  os  calcis 
cleared  before  the  disarticulation  is  attempted. 

3.  Verneuirs  Operation. — This  procedure  appears  to  be 
one  that  is  very  generally  adopted  in  France  (Fig.  114;  v). 

The  incision 
is  commenced 
over  the  outer 
tuberosity  of  the 
OS  calcis,  from  2 
to  3  cm.  below 
the  external 
malleolus.  It  is 
then  carried  for- 
ward to  a  point 
2  cm.  behind, 
and  to  the  inner 
side  of  the  base 
of  the  fifth 
metatarsal  bone. 
It  is  now  curved  over  the  dorsum  of  the  foot  to  the  middle 
of  the  internal  cuneiform  bone.  Finally,  it  sweeps  obliquely 
across  the  sole,  to  reach  the  point  of  commencement  by  the 
shortest  possible  route. 

The  soft  parts  are  cleared  from  the  bone,  and  the  disarticu- 
lation effected  as  above  described.  It  is  advisable  to  saw  off 
the  head  of  the  astragalus.  ^ 

4.  Disarticulation  with  a  Heel  Flap. — The  flaps  made  in 
this  operation  are  a  modification  of  those  of  Syme's  amputa- 
tion (page  445).  The  plantar  incision  commences  half  an  inch 
below  the  outer  malleolus,  and  ends  one  inch  below  the  inner 
malleolus.  Between  these  points  it  is  carried  vertically 
downwards  across  the  heel,  while  the  foot  is  held  at  right 
angles  to  the  leg.  The  dorsal  flap  is  U-shaped,  has  its  limbs 
horizontal,  and  crosses  the  foot,  with  a  curve,  at  the  level  of  the 
astragalo-scaphoid  joint  (Fig.  117,  b). 

The  heel  flap  is  dissected  back  just  as  in  Syme's  amputa- 


iJ  A 

Fig.  116. — A,  Disarticulation  of  the  little  toe,  together  with 
its  metatarsal  bone,  by  the  oval  or  racket  incision  ;  B, 
Maurice  Perrin's  subastragaloid  amputation. 


SUBASTRAGALOID    AMPUTATION. 


441 


tion  (page  446),  and  the  tendo  Achillis  is  then  divided.  The 
dorsal  tiap  is  in  the  next  place  dissected  up,  and  must  include 
all  the  soft  parts  down  to  the  bone. 

The  astragalo-scaphoid  joint  having  been  opened  from  the 
dorsum,  the  knife  is  passed  between  the  astragalus  and  os 
calcis,  and  the  disarticulation  is  eflfected.  Ashhurst  advises 
that,  as  soon  as  the  flaps  have  been  made,  the  anterior  part  of 
the  foot  should  be  disarticulated  along  the  Hue  of  Chopart's 
operation,  that 
the  OS  calcis 
should  then  be 
grasped  with  a 
pair  of  lion  for- 
ceps and  twisted 
from  side  to  side 
while  the  separa- 
tion from  the 
astragalus  is  ef- 
fected. 

The  head  of 
the  astragalus 
should  be  re- 
moved with  the 
saw.    The  vessels 

divided  are  practically  the  same  as  those  cut  m  Syme's 
operation. 

Comment. — Subastragaloid  amputation  was  proposed  by 
LigneroUes  in  1839,  was  first  performed  in  Germany  by 
Textor  in  1841,  in  France  by  Malgaigne  in  1845,  and  in 
England  by  Simon  in  1848.  Malgaigne  employed  a  single 
large  internal  flap,  and  Nelaton  peculiar  dorsal  and  plantar 
flaps  that  were  larger  on  the  inner  than  the  outer  side. 

The  amputation  gives  very  excellent  results.  The  astr?  • 
galus  forms  a  good  surface  for  support,  and,  as  the  ankle- 
joint  is  preserved,  a  more  elastic  stump  is  produced  than 
results  from  either  Syme's  or  Pirogoff's  amputation. 

Of  the  four  methods  described,  the  first  three  are 
practically  varieties  of  the  oval  or  racket  incision,  the  last 
involves  a  simple  heel  flap. 

Farabeufs  operation  has  been  considered  first  because  it 


■A,  Disaiticiilation  of  the  great  toe,  together  with 
its  metatarsal  bone,  by  the  oval  or  racket  incision  ;  B, 
subastragaloid  amputation  by  heel  flap. 


442  OPERATIVE    SURGERY. 

serves  to  demonstrate  the  especial  features  of  the  operations 
by  the  oval  method  and  the  difficulties  of  disarticulating. 
The  resulting'  flap  affords  an  excellent  covering  to  the  bone, 
the  head  of  the  astragalus  can  be  left,  and  the  cicatrix  is  well 
removed  from  pressure.  The  incision  is,  however,  needlessly 
complex,  the  flap  is  a  little  unwieldy,  a  rather  large  pocket 
is  formed  about  the  heel,  and  it  is  not  easy  to  obtain  in 
every  case  so  large  a  tract  of  sound  skin  as  is  demanded- 
Yerneuil's  operation  is  much  simpler,  but,  if  conducted  pre- 
cisely upon  the  lines  laid  down,  the  resulting  flap  is  a  little 
scanty.  So  far  as  my  experience  goes,  I  should  say  the  choice 
of  a  subastragaloid  amputation  rested  between  the  procedure 
of  Maurice  Perrin  and  that  by  the  heel  flap.  I  have  once  had 
the  opportunity  of  performing  both  operations  at  the  same 
time,  upon  the  same  patient,  for  troubles  following  upon 
extreme  talipes  varus. 

Perrin's  operation  is  difiicult ;  the  soft  parts  are  somewhat 
roughly  handled,  and  there  are  many  risks  of  injuring  the 
vessels  of  the  flap.  The  wound  will  probably  not  heal  so 
well  as  after  the  operation  by  the  heel  flap.  The  latter  pro- 
cedure is  simple,  is  easy,  and  can  be  carried  out  with  a  mini- 
mum amount  of  disturbance  to  the  soft  parts.  The  wound 
heals  readily. 

When  the  stumps,  however,  have  become  firm,  some  im- 
portant points  of  difference  are  to  be  noted : — The  stump  in 
the  oval  operation  is  wide,  and  the  cicatrix  is  well  removed 
from  pressure  ;  in  the  heel-flap  procedure  the  stump  is  narrower, 
and  the  suture  line  comes  inconveniently  near  to  the  pressure 
area.  In  patients  in  whom  excellent  healing  powers  may  be 
expected,  I  think  Perrin's  method  is  to  be  preferred. 

In  theee  operations  a  drainage-tube  may  be  retained  for 
one  or  two  days.  The  limb  should  be  supported  on  an 
inclined  plane  on  a  simple  back-splint.  The  sutures  should 
be  retained  as  long  as  possible,  and  after  their  removal  the 
flap  may  be  su])])orted  by  straj^ping. 

THE   AFTER-T11E.\TMENT  OF  PARTIAL  AMPUTATIONS  OF  THE  FOOT. 

Tlic  wound  should  be  kept  exposed  to  the  air  for  reasons 
already  given  (page  69),  the  limb  should  be  a  little  raised 
upon  a  pillow,  and  the  stump  sliould  bo  so  placed  that  efficient 


PARTIAL    AMPUTATION    OF   FOOT.  443 

drainage  is  permitted.  The  remarks  already  made  with 
reference  to  the  after-treatment  of  amputations  of  the  toes 
apply  to  certain  of  these  operations  (page  41 G). 

In  the  case  of  the  removal  of  the  great  toe,  together  with 
its  nietatarsal  bone,  the  foot  should  be  allowed  to  he  a  little 
upon  its  inner  side,  provided  that  direct  pressure  is  not  made 
upon  the  wound.  When  the  tifth  toe  has  been  removed  in  a 
similar  manner,  the  foot  should  be  inclined  towards  the 
opposite  side. 

After  Lisfranc's  and  Hey's  amputations  the  limb  may  be 
allowed  to  lie  upon  one  or  other  side  with  the  knee  bent.  The 
pillow  supporting  the  foot  should  be  firm,  the  stump  may  pro- 
ject a  little  beyond  the  end  of  the  pillow,  and  to  this  support 
the  leg  may  be  lightly  secured. 

After  Chopart's  operation  and  after  the  subastragaloid 
amputations  the  stump  should  be  supported,  upon  a  back- 
splint,  which  is  kept  a  little  raised  by  a  firm  pillow  or  cushion. 
By  this  means  the  heel-flap  is  supported,  and  the  os  calcis  in 
the  Chopart  operation  is  to  a  great  extent  kept  from  altering 
its  position.  The  knee  should  be  a  little  bent,  and  the  stump 
may  be  inclined  laterall}',  so  as  to  favour  drainage.  The  splint 
employed  is  an  ordinary  straight  back-splint,  suitably  padded. 

A  pad  is  introduced  beneath  the  tendo  Achillis.  The  skin 
is  protected  by  a  piece  of  gutta-percha  moulded  to  the  limb 
and  lined  with  lint.  The  splint  is  secured  by  straps  and 
buckles  (Fig.  76). 

Drainage-tubes  should  not  be  employed  unless  actually 
necessary,  and  should  never  be  passed  right  across  the  angle  of 
the  wound,  from  one  extremity  of  the  incision  to  the  other. 
A  small  piece  of  tubing  may  be  introduced  at  each  of  the  two 
corners  of  the  wound — as  in  Hey's,  Lisfranc's,  and  Chopart's 
amputations — and  sutures  at  these  pomts  may  be  omitted. 
In  any  case  the  tubes  should,  under  ordinary  circumstances, 
be  removed  in  twenty -four  hours. 

In  the  subastragaloid  operations,  where  a  heel-flap  exists — 
with  a  pouch  left  b}'  the  removal  of  the  os  calcis — a  hole  may 
be  made  through  the  centre  of  that  flap  into  the  pouch,  and  a 
short  length  of  tube  introduced.  This  need  not  be  retained 
more  than  one  day. 


j,/[,.]^ 


CHAPTEK    XXVI. 

Amputation  of  the  Foot. 

Two  procedures  will  be  described : — 

A.  Disarticulation  at  the  ankle-joint. 

B.  Intra-calcaneal  amputations  of  the  foot. 

a. — disarticulation  at  the  ankle-joint    (syme'b 
amputation). 

This  is  the  principal  operation  for  removing  the  entire 
foot.  The  flap  is  made  from  the  heel,  the  soft  parts  having 
been  peeled  off  the  os  calcis.  The  two  malleoli,  together  with 
the  articular  surface  of  the  tibia,  are  sawn  off. 

Anatomical  Points. — The  mechanical  characters  of  the 
ankle-joint  should  be  well  known,  and  the  height  and  breadth 
of  the  dome  on  the  tibia,  which  receives  the  head  of  the 
astragalus,  duly  appreciated. 

The  anterior  and  posterior  hgaments  of  the  ankle-joint 
are  very  thin,  but  the  lateral  ligaments — and  especially  the 
mtemal  lateral  ligament — are  very  strong,  and  have  wide  and 
extended  attachments  to  the  tarsal  bones.  The  chief  tendons 
about  the  ankle-joint  run  in  synovial  sheaths,  and  are  therefore 
difficult  to  cut  unless  the  knife  be  wielded  with  vigour. 

The  blood  supply  of  the  heel-flap  is  a  matter  of  great 
importance ;  the  two  chief  vessels  of  supply  are  the  external 
calcaneal  of  the  posterior  peroneal  on  the  outer  side,  and  the 
internal  calcaneal  of  the  external  plantar  on  the  inner  side. 
The  first-named  vessel  is  a  continuation  of  the  posterior 
peroneal.  It  runs  just  behind  the  inferior  tibio-fibular  joint, 
and  then  behind  the  outer  malleolus  to  the  heel.  With  regard 
to  the  internal  calcaneal  artery,  the  posterior  tibial  divides 
"on  a  level  with  a  line  drawn  from  the  point  of  the  internal 
malleolus  to  the  centre  of  the  convexity  of  the  heel."  This  line 
is  dangerously  close  to  the  line  of  the  incision.  The  internal 
calcaneal  artery  arises  from  the  external  plantar,  close  to  the 
bifurcation   and   under   the   fibres   of  origin  of  the  abductor 


AMPUTATION   OF   FOOT.  445 

pollicis.     Inasinuch  as  this  is  the  chief  vessel  of  the  flap,  the 
greatest  care  must  be  taken  of  it.     (See  page  448.) 

Minute  branches  may  reach  the  flap  from  the  internal 
malleolar  of  the  posterior  tibial  and  from  the  outer  and  inner 
malleolar  of  the  anterior  tibial. 

The  lower  epiphyfiis  of  the  tibia  includes  the  articular 
surface  and  the  inner  malleolus.  It  joins  the  shaft  between 
the  eighteenth  and  nineteenth  years.  The  lower  epiphysis  of 
the  fibula  corresponds  to  the  outer  malleolus,  and  joins  the 
shaft  about  the  twenty-first  year. 

The  OS  calcis  has  an  ej^iphysis  for  its  posterior  extremity 
It  forms  a  cartilaginous  shell  for  that  part  of  the  bone.  It 
does  not  commence  to  ossify  until  the  tenth  year,  and  does 
not  join  the  body  of  the  bone  until  fifteen  or  sixteen. 

In  removing  the  lower  ends  of  the  tibia  and  fibula  the 
greater  part  of  the  anterior  and  posterior  tibio-fibular  liga- 
ments, together  with  the  interosseous  ligament,  are  saved,  while 
the  transverse  or  inferior  ligament  is  cut  away  with  the  bones. 

Instruments. — A  stout  narrow  knife,  with  a  blade  three 
inches  long,  a  narrow  but  rounded  point,  and  a  large 
strong  handle ;  a  scalpel ;  a  saw ;  two  metal  retractors  to  hold 
back  the  flaps  when  sawing  the  leg  bones;  lion  forceps;  pressure 
forceps  ;  artery  and  dissecting  forceps,  scissors,  etc. 

Position. — The  patient  lies  on  the  back,  with  the  foot  pro- 
jecting beyond  the  end  of  the  table,  and  the  toes  pointing 
upwards.  The  surgeon  sits  facing  the  end  of  the  table.  The 
lower  end  of  the  leg  is  raised  on  a  Volkmann's  pelvic  support 
to  the  level  of  the  surgeon's  face.  The  surgeon  sits  to  cut  the 
heel  flap,  and  stands  to  cut  the  dorsal  flajD  and  to  disarticulate. 
Two  assistants  stand  facing  the  surgeon,  one  on  each  side  of 
the  end  of  the  table.  One  steadies  the  foot,  the  other  attends 
to  the  w^ound. 

The  Operation. — An  assistant  steadies  the  leg  with  one 
hand,  and  holds  the  foot — by  the  toes — rigidty  at  a  right  angle 
to  the  leg  with  the  other  hand. 

1.  The  Heel  Flap. — The  incision  starts  from  the  tip  of  the 
outer  malleolus,  and  in  a  line  nearer  to  its  posterior  than  its 
anterior  border. 

It  is  carried  verticall}^  down  the  heel,  exactly  at  right 
angles  to  the  long  axis  of  the  foot,  runs  transversely  across 


U6 


OPERATIVE    SURGERY. 


the  sole,  and  passing  up  vertically  on  the  inner  side  of  the 
heel,  ends  at  a  point  about  half  an  inch  below  the  tip  of  the 
inner  malleolus  (Fig.  118,  d). 

In  making  this  incision,  supposing  the  right  foot  to  be 
operated  on,  the  surgeon  holds  the  ankle  with  the  palm  of  his 
left  hand  on  the  dorsum  of  the  foot,  with  his  thumb  on  the 
outer  malleolus,  and  his  forefinger  on  the  inner  malleolus. 

Entering  the  Icnife  at  the  inner 
starting-point,  the  incision  is  carried 
down  to  the  sole  and  then  across 
the  plantar  aspect  of  the  os  calcis  at 
one  cut.  The  knife  is  now  re-entered 
at  the  outer  starting-point,  and  i& 
carried  down  to  meet  the  first  in- 
cision at  the  sole.  If  an  attempt 
be  made  to  perform  the  incision  at 
one  cut,  and  to  make  the  outer  limb 
of  the  incision  by  cutting  from  the 
heel  towards  the  leg,  the  knife  may 
slip  and  cut  too  far  up  into  the  leg,, 
running  by  the  starting-point.  On 
the  left  foot  the  same  precaution  is. 
observed,  but  the  incision  is  com- 
menced on  the  outer  side. 

This  incision  should  be  carried 
well  and  cleanly  down  to  the  bone. 
The  heel  flap  is  now  dissected  back  : 
the  thumb-nail  of  the  left  hand  i& 
used  with  force  to  drag  back  the 
soft  parts,  while  the  knife  is  kept 
well  on  to  the  bone  and  parallel  to  the  surface  of  the  fla]>. 
The  OS  calcis  must  be  laid  perfectly  bare.  The  great  point  in^ 
Syme's  amputation  is  to  "keep  close  to  the  bone." 

The  flap  must  be  cleared  from  the  tuberosities  of  the  os 
calcis,  and  then  from  its  posterior  surface. 

2.  The  Dorsal  Incision. — The  surgeon  now  holds  the  foot 
in  the  left  hand  in  the  position  of  the  full  extension,  and  con- 
nects the  extremities  of  the  heel  incision  by  a  cut  which  simply 
sweeiDs  across  the  front  of  the  ankle  region.  The  dorsal  and 
the  heel  incisions  arc  about  at  right  angles  to  one  another 


Fig.     118.— PLANIAR  INCISIONS. 

A,  Lisfranc  :  n,  Cliopart  ;  c, 
Pirogoff  :  D,  Syme  ;  E,  Fara- 
beuf's  .subastragaloid  amim- 
tation  ;  V,  Faiabeuf's  ampu- 
tation at  the  ankle. 


SYME'S    AMPUTATION. 


447 


(Fig.  119).  The  cut  inclndes  all  the  soft  parts  down  to  the 
bone.  The  tendons  must  be  cleanly  divided  while  the  foot  is 
kept  on  the  stretch. 

3.  The  Disarticulation. — The  ankle-joint  is  at  once  ex- 
posed, the  anterior  ligament  having  been  severed.  The  knife 
is  now  introduced  into  the  joint  and  the  lateral  ligaments  are 
divided,  in  both  instances  by  cutting  from  within  outwards. 
These  complex  ligaments  are  difficult  to  cut  if  attacked  from 
the  outer  side  of  the  articulation.  The  posterior  ligament  is 
cut,  the  upper  surface  of  the  os  calcis  is  cleared,  and  by  the 
division  of  the  tendo  Achillis  the  dis- 
articulation is  completed. 

4  The  Removal  of  the  Malleoli. — The 
soft  parts  are  cleared  from  the  two 
malleoli  and  the  lower  end  of  the  tibia, 
great  care  being  taken  not  to  damage 
the  flaps.  The  exposed  bones  are  then 
divided  by  a  horizontal  saw-cut,  the  saw 
being  applied  about  a  quarter  of  an 
inch  above  the  inferior  margin  of  the 
tibia. 

The  flaps  may  be  protected  by 
spatulte  during  the  sawing.  If  it  should 
be  necessary,  the  malleoli  may  be  held  with  lion  forceps. 

Before  the  wound  is  adjusted  by  sutures,  a  hole  may  be 
made  in  the  centre  of  the  heel  flap,  and  a  drainage-tube 
introduced. 

Hoiinorrhage. — The  anterior  tibial  artery  is  cut  in  the 
dorsal  flap  just  opposite  the  centre  of  the  front  of  the  ankle. 
The  external  and  internal  plantar  arteries  are  divided  in 
the  inner  section  of  the  heel  flap.  The  two  vessels  are  close 
together.  The  following  vessels  may  give  rise  to  hiemorrhage  : 
the  internal  malleolar  of  the  posterior  tibial  behind  the  inner 
malleolus;  the  anterior  peroneal  in  front  of  the  tibio-fibular 
joint ;  the  external  and  internal  malleolar  of  the  anterior  tibial 
in  front  of  their  corresponding  malleoli.  The  internal 
saphenous  vein  is  cut  in  the  dorsal  flap,  the  external  in  the 
heel  flap. 

Coinment. — This  amputation  gives  admirable  results,  and 
secures  a.  sound  and  tirm  stump.     The  patient  walks  upon 


119. — syme's  amputa- 
tion OF  THE  FOOT. 


448  OPERATIVE    SURGERY. 

the  natural  tissues  of  the  heel.  The  tendo  Achillis  forms  an 
attachment  with  the  mass  of  the  cicatrix.  With  a  properly 
adapted  boot,  a  patient  after  Syme's  amputation  can  walk  with 
little  appreciable  lameness. 

The  mortahty  of  this  operation  in  338  cases  is  9"7  per  cent. 
(  A.shhurst). 

The  following  special  points  in  the  operation  must  be 
noted  :— 

1.  It  is  important  that  the  flap  should  be  accurately  cut. 
In  some  text-books  it  is  advised  that  the  incision  be  carried 
from  the  tip  of  the  outer  malleolus  to  a  point  half  an  mch 
behind  and  below  the  inner  malleolus.  If  this  be  done,  there 
is  great  probability  that  the  posterior  tibial  artery  will  be 
divided  before  its  bifurcation,  and  the  main  artery  of  the  flap 
(the  internal  cal'^aneal  of  the  external  plantar)  be  thus  lost. 

The  following  are  Sjrme's  own  words  : — "  The  incisions  must 
be  correctly  made.  A  transverse  one  should  be  carried  across 
the  sole  of  the  foot,  from  the  tip  of  the  external  malleolus,  or  a 
httle  posterior  to  it  (rather  nearer  the  posterior  than  the 
anterior  edge  of  bone)  to  the  opposite  point  on  the  inner  side, 
which  will  be  rather  below  the  tip  of  the  internal  malleolus." 
Thus  the  inner  part  of  the  heel  flap  is  a  httle  larger  than  the 
outer. 

If  the  flap  be  too  large,  there  is  great  difficulty  in  dissect- 
ing it  back,  and  it  will  probably  be  dangerously  scored  and 
bruised  in  the  attempt. 

2.  In  clearing  the  os  calcis,  the  periosteum  may  be  at  the 
same  time  peeled  off — as  many  advise — and  so  made  to  form 
an  important  constituent  of  the  heel  flap.  In  young  subjects 
(under  the  age  of  fourteen  years)  the  posterior  epiphysis  of  the 
OS  calcis  may  be  detached  and  left  undisturbed  in  the  flap. 

In  such  subjects  it  generally  comes  away  during  the 
process  of  clearing  the  os  calcis. 

In  still  younger  jmtients — say  those  under  ten — the  super- 
ficial parts  of  the  os  calcis  will  be  found  imperfectly  ossified, 
and  chunks  of  the  soft  bone  may  be  cut  away  in  a  too 
vigorous  clearing  of  the  heel  flap. 

3.  It  is  desirable  that  all  the  articular  surface  of  the  tibia 
should  be  removed,  and,  as  the  under-surface  of  the  bone  is 
much  domed,  the  section  must  be  made  as  high  \xp  as  a  quarter 


BOUX'S    AMPUTATION. 


449 


of  an  inch  to  quite  clear  the  summit  of  the  concavity.  In 
young  patients  the  Avhole  of  the  lower  epiphysis  may  be 
removed  by  a  too  liberal  use  of  the  saw;  the  measurement 
(quarter  of  an  inch)  refers  to  adults. 

Other  Methods. 

Roaxs  Operation. — This  is  a  modified  form  of  the  oval 
method. 

The  dorsal  incision  is  commenced  at  the  posterior  edge 
of  the  outer  face  of  the  os  calcis,  is  carried  forwards  just  below 
the  external  malleolus,  and  then  crosses  the  dorsum  of  the  foot 
one  inch  in  front 
of     the     ankle- 
joint,  to  a  point 
between  the  tu- 
bercle    of     the 
scaphoid        and 
the    inner   mal- 
leolus, and  on  a 
level    with    the 
tij)  of  the  latter 
process        (Fig. 
120). 

The  plantar 
incision  starts  from  the  last-named  point,  and  curving  for- 
wards a  little,  crosses  the  inner  border  of  the  foot,  at  about 
the  level  of  the  scaphoid.  It  is  then  carried  across  the 
sole  to  a  point  about  one  inch  behind  the  tuberosity  of  the 
fifth  metatarsal  bone,  and  thence  up  to  the  point  de  depart. 
The  flaps  are  dissected  back  as  far  as  possible,  the  foot  is  dis- 
articulated, and  the  soft  parts  are  then  dissected  away  from 
the  inner  side  of  the  os  calcis  in  somewhat  the  same  manner 
as  is  described  in  Farabeufs  subastragaloid  amputation. 

The  malleoli  are  removed  as  in  Syme's  amputation. 

The  procedure  is  difficult  and  tedious,  and  is,  on  the  whole, 
inferior  to  Syme's  operation.  The  flap,  if  well  cut,  is  certamly 
better  nourished,  but  a  greater  demand  is  made  upon  the 
integuments  of  the  foot. 

Fii.raheufs  Operation. — In  all  essential  points  this  opera- 
tion is  identical  with  the  subastragaloid  amputation   of  the 
same  surgeon  (page  436). 
D  r> 


Fig.    120.— ROUX'S   AMPtFTATION. 


450  OPERATIVE    SURGERY. 

The  incision  is  commenced  on  the  outer  side  at  the 
insertion  of  the  tendo  Achillis.  It  is  carried  horizontally 
forward  (touching  the  tip  of  the  external  malleolus)  to  a  point 
just  in  front  of  the  calcaneo-cuboid  joint  (corresponding  to  b. 
Fig.  114).  It  then  crosses  the  dorsum  to  reach  the  extensor 
proprius  pollicis  tendon,  just  in  front  of  the  astragalo-scaphoid 
joint  (corresponding  to  x,  Fig.  114).  It  now  sweeps  over  the 
inner  border  of  the  foot,  crossing  the  scapho-cuneiform  joint 
(corresponding  to  x  to  c,  Fig.  114  and  B,  Fig.  121),  and  is 
then  carried  back  along  the  median  line  of  the  sole  (corre- 
sponding to  D  to  E,  Fig.  114,  and  f.  Fig.  118),  to  end  at  the 
insertion  of  the  tendo  Achillis.  The  flaps  are  dissected  back 
as  far  as  convenient,  the  ankle-joint  is  opened  from  the  outer 
aspect  of  the  foot,  and  the  disarticulation  and  the  clearing 
of  the  OS  calcis  are  effected  precisely  in  the  manner  already 
described. 

A  good  thick  vascular  flap  is  provided,  but  the  operation 
is  less  easy  to  execute  than  Syme's,  and  has  no  distinct  advan- 
tage over  that  admirable  procedure. 

B. — INTRA-CALCANEAL   AMPUTATIONS    OF   THE    FOOT. 

Pirogoff's  Operation. — This  operation  closely  resembles- 
Syme's,  save  that  the  os  calcis  is  saAvn  through,  and  its  hinder 
part  is  left  in  the  heel  flap.  The  lower  ends  of  the  tibia  and 
flbula  are  sawn  through,  and  to  this  cut  surface  of  bone  the 
surface  of  the  divided  os  calcis  is  adjusted. 

The  operation  usually  described  is  a  modification  of 
Pirogoti"s  original  procedure.  Pirogoff  divided  the  calcaneinn 
vertically,  and  left  the  articular  surface  of  the  tibia,  unless  it 
was  diseased. 

Position  and  Instruments. — The  same  as  in  Syme's 
operation.  The  saw  should  either  be  a  fine  Butcher's  saw, 
or  a  slender  saw  wdth  a  movable  back.  Retractors  are 
required. 

Operation. — The  incisions  are  nearly  the  same  as  in  Syme's 
operation,  with  these  modifications : — They  commence  on  the 
outer  side,  just  in  front  of  the  tip  of  the  malleolus,  and  end  on 
the  inner  side  a  fcAv  lines  in  front  of  the  internal  process.  The 
heel  incision  is  carried  a  little  farther  forward  than  in  Syme's 
operation  (Fig.  118,  c).     It  is  carried  well  down  to  the  hone. 


FIROGOFF'S    AMPUTATION. 


451 


The  soft  parts  are  dissected  backwards  from  the  os  calcis  for 
about  a  quarter  of  an  inch. 

The  dorsal  cut  is  then  carried  out,  and  may  be  a  Httle 
more  convex  than  in  Syme's  amputation.  The  ankle-joint 
is  opened,  and  disarticulation  effected  precisely  as  already 
described. 

The  foot  is  now  dragged  forward  and  placed  in  the  position 
of  full  extension. 

The  whole  of  the  upper  surface  of  the  os  calcis  is  exposed. 
The  saw  is  now  applied  to  this  surface,  one  finger's-breadth 
behind  the  astragalus,  and  is  made  to  cut  the  bone  obHquely, 
following  the 
lines  of  the 
now  distorted 
heel  -  incision. 
In  sawing  the 
bone,  the  soft 
parts  must  be 
carefully  re- 
tracted, and,  in 
the  position  in 
tvhich  the  foot 
is  held,  the  saw 
runs  nearly 
vertically  (Fig. 
121,  c).  The 
greatest      care 

must  be  taken  not  to  damage  the  arteries  in  the  inner  part  of 
the  heel  flap. 

The  soft  parts  are  now  dissected  from  the  lower  ends  of 
the  tibia  and  fibula.  The  saw  is  applied  to  the  anterior  aspect 
of  these  bones,  close  to  the  articular  surface  of  the  tibia,  and  is 
made  to  cut  so  obliquely  upwards  that  the  saw  emerges  on 
the  posterior  aspect  of  the  tibia,  a  finger's-breadth  above  the 
articular  surface  (Fig.  121,  c).  Any  unduly  long  tendons 
are  divided.  The  wound  is  sutured  as  in  Syme's  operation, 
the  cut  surfaces  of  bone  being  thus  brought  into  close 
contact. 

Care  must  be  taken  in  the  after-treatment  that  the  heel 
fragment  is  not  dra\vn  up  by  the  tendo  Achillis, 

D  D  2 


Fig.  121. — A,  Farabeuf  s  subastragaloid  amputation  ;  B,  Fara- 
beuf's  amputation  at  the  ankle-joint ;  C  C,  Saw-cuts  in 
Pirogoff's  operation  ;  D  D,  Saw-cuts  in  Pasquier  and  Le 
Fort's  operation :  D  shows  also  the  saw-cut  made  in  the 
OS  calcis  in  Tripier's  operation. 


45: 


UPERATIVE    SURGERY. 


The  vessels  divided  are  the  same  as  in  the  preceding 
operation. 

Comonent. — Some  surgeons  make  much  larger  heel  flaps, 
carrying  the  incision  forwards  and  downwards,  so  as  to  cross 
the  calcaneo-cuboid  joint,  instead  of  directing  it  nearly  ver- 
tically do-uTiwards  from  the  malleoli. 

This  operation  does  not  appear  to  have  been  very  widely 
•employed.  It  is  suited  for  certain  cases  of  accident,  but  not 
for  cases  of  disease. 

It  presents  these  advantages  when  compared  with  Syme's 
operation : — 

The  heel  flap  is  much  less  likely  to  slough ;  the  stump  is 
longer  by  one  or  two  inches,  is  firmer,  does  not  shrink,  and 
contains  bone ;  the  insertion  of  the  tendo  Achillis  is  not  dis- 
turbed. On  the  other  hand,  Pirogoff's  ojDeration  is  no  easier  to 
perform  than  Syme's ;  the  piece  of  bone  in  the  heel  is  apt  to 
become  displaced  by  the  action  of  the  calf  muscles ;  it  may 
fail  to  unite,  may  necrose,  and  has  led  to  a  painful  stump ;  a 

wider  section  of  cancellous  bone 
is  left,  and  greater  demands 
are  made  upon  the  healing 
powers.  The  ojjeration  would 
not  be  likely  to  succeed  with 
elderly  subjects.  So  far  as 
movement  is  concerned,  it  has 
not  been  shown  that  the  stum]:> 
is  always  very  decidedly  im- 
proved by  the  retention  of  a 
portion  of  the  calcanonm. 

Le  Fort's  Operation. — This 
is  a  modification  of  Pirogoff's 
procedure.  It  is  described  by  Farabeuf  as  "Pasquier-Le  Fort's 
operation." 

The  skin  incisions  are  somewhat  the  same  as  in  Roux's 
method,  with  the  exceptions  that  the  incision  on  the  outer 
side  is  carried  back  to  the  insertion  of  the  tendo  Achillis  and 
the  wound-lines  conform  to  the  racket  rather  than  to  the 
oval  operation  (Fig.  ]  22). 

The  calcaneum  is  cut  horizontally  just  below  the  sustenta- 
culum tali  (Fig.  121,  D). 


Fig. 


122. — PASaUIEB     AND     LE    FOET'S 
OPEEATION. 


LE   FORT'S    AMPUTATION.  455 

The  incision  having  been  carried  to  the  bone,  the  soft  parts 
are  dissected  back  as  far  as  possible,  especially  on  the  dorsum 
and  about  the  external  part  of  the  wound.  The  ankle-joint  is 
opened  from  the  outer  side,  the  anterior  and  external  ligaments 
being  first  attacked.  The  disarticulation  is  made  complete, 
and  the  foot  rotated  very  strongly  outwards,  so  that  the 
astragalus  presents  at  the  outer  part  of  the  wound. 

The  astragalus  is  now  seized  with  large  lion  forceps  and 
turned  (together  with  the  whole  foot)  still  more  outwards, 
until  at  last  the  forceps  are  quite  horizontal.  The  upper  portion 
of  the  OS  calcis  is  carefully  cleaned,  and  all  the  part  of  the  bone 
that  requires  removal  will  now  be  seen  in  the  outer  wound, 
the  inner  surface  of  the  os  calcis  looking  directly  upwards. 
The  saw  is  applied  to  the  surface,  just  below  the  sustenta- 
culum tah,  and  the  bone  is  divided  quite  horizontally.  The 
msertion  of  the  tendo  Achillis  is  preserved.  The  inferior  and 
lateral  ligaments  of  the  calcaneo-ciiboid  joint  having  been 
divided,  the  foot  is  free. 

The  lower  ends  of  the  tibia  and  fibula  are  savm  through 
horizontally,  just  above  the  articular  surface  for  the  ankle- 
joint  (Fig.  121,  d). 

It  is  claimed  that  this  procedure  is  superior  to  PirogofPs, 
on  the  following  grounds : — A  good  thick  flap,  well  supplied 
with  blood,  is  provided.  A  larger  amount  of  the  soft  parts  that 
cover  the  heel  is  saved.  The  whole  lens^th  of  the  os  calcis 
rests  upon  the  ground,  and  the  patient  is  provided  with  a  wider 
area  of  support.  The  parts  are  left  in  a  more  natural 
position. 

Tripier's  Operation. — This  operation  is  really  a  modifi- 
cation of  Chopart's  amputation. 

In  that  procedure  some  difficulty  is  often  experienced  by 
the  tilting  of  the  heel-stump  in  the  position  of  talipes  equinus. 
Tripier  seeks  to  avoid  this  by  making  a  wide  horizontal 
section  of  the  os  calcis,  so  that  the  stump  may  present  a  broad 
and  level  basis  of  support.     An  excellent  flap  is  provided. 

The  dorsal  incision  has  its  concavity  upwards  and  inwards. 
It  commences  at  the  outer  edsfe  of  the  tendo  Achillis,  on  a 
level  with  the  tip  of  the  external  malleolus.  It  sweeps 
forwards  about  one  inch  below  that  point  of  bone,  passes  a 
finger 's-breadth  behind  the  tuberosity  of  the  metatarsal  bone. 


454 


OPERATIVE    SURGERY. 


and  ends  at  the  inner  side  of  the  extensor  proprius  polHcis 
tendon,  two  fingers'-breadths  in  front  of  the  ankle-joint.  The 
plantar  incision  commences  at  this  point,  is  carried  over  the 
inner  cuneiform  bone  at  the  internal  margm  of  the  foot,  sweeps 
with  a  curve  across  the  sole,  reaches  the  outer  edge  of  the 
foot  about  the  base  of  the  fifth  metatarsal,  and  then  joins  the 
dorsal  incision  (Fig.  123). 

The  incision  extends  to  the  bone.  The  flaps  are  dissected 
back  so  as  to  make  clear  the  medio-tarsal  joint.  Disarticula- 
tion is  now  effected  as  in  Chopart's  operation.  With  a 
rugine  the  whole  of  the  under  part  of  the  os  calcis  is  bared 
of  periosteum,  the  plantar  flap  having  been  dissected  up  as 
hiofh  as  the  sustentaculum  tali.  The  os  calcis  is  now  seized 
with  lion  forceps  and  so  turned  as  to 
well  expose  its  inner  surface.  The  saw- 
cut  is  made  horizontal!}^,  just  below  the 
sustentaculum,  and  runs  from  the  inner 
to  the  outer  surface  (Fig.  121,  d).  The 
angle  which  the  cut  surface  of  the  os 
calcis  forms  with  the  cuboid  surface  of 
that  bone  is  finally  rounded  off'  with  the 
saw,  and  the  operation  is  complete. 

THE    AFTER-TREATMENT   OF   AMPUTATIONS 
OF  THE   FOOT. 

Many  of  the  observations  already 
made  with  reference  to  the  after-treat- 
ment of  amputations  of  the  toes  and  of 
portions  of  the  foot  apply  to  the  present 
procedures. 

The  stump  should  be  kej)t  exposed  to 
the  air. 

The  limb  should  be  a  Httle  raised 
upon  a  firm  pillow. 

A    back-splint    should   be    adjusted 
precisely  as  advised  m  the  case  of  some 
of  the  previous  operations  (page  309,  Fig.  76). 

Care  must  be  taken  that  the  pad  of  the  splint  does  not 
press  imduly  upon  the  extremity  of  the  stump.  This  splint 
serves  to  support  the  heel  flap,  and,  m  the  case  of  the  intra- 


123. — teipiee's  ope- 

EATIOX. 


AMPUTATION    OF   FOOT.  455 

calcaneal  amputations,  it  helps  also  to  keep  the  osseous  surfaces 
in  contact,  and  to  restrain  the  action  of  the  muscles  of  the 
calf. 

The  knee  should  in  all  mstances  be  a  little  bent,  and  the 
stump  may,  when  required,  be  inclined  a  little  laterally,  to 
favour  drainage. 

Drainage-tubes  should  not  be  employed  when  their  use 
can  be  avoided.  They  should  never  be  passed — as  is  some- 
times done  in  Sj^me's  operation- — right  across  the  angle  of  the 
wound  from  one  extremity  of  the  incision  to  the  other.  In 
the  intra-calcaneal  methods  a  short  piece  of  tubing  may  be 
inserted  at  the  most  dependent  part  of  the  wound,  or  the 
wound  be  allowed  to  gape  a  little  at  that  point. 

Where  a  heel  flap  exists,  with  a  pouch  beneath,  left  by  the 
removal  of  the  os  calcis — as  in  Syme's  operation — a  hole  may 
be  made  into  the  pouch  through  the  centre  of  the  flajD,  and  a 
short  length  of  tubing  introduced.  This  need  not  be  retained 
for  longer  than  a  day. 

When  the  major  flap  is  formed  from  the  heel  or  sole,  it 
should  be  remembered  that  the  tissues  of  those  parts  are 
usually  tough  and  unyielding,  and  that  consequently  an  undue 
strain  comes  upon  the  sutures.  These  should  be  deeply 
inserted,  and  should  not  be  removed  too  soon.  In  a  "  Syme  " 
they  may  often  be  retained  for  ten  days.  After  their  removal 
it  may  be  necessary  to  support  the  f^ap  with  strips  of 
strapping. 


456 


CHAPTER    XXYII. 

OSTEO-PLASTIC   RESECTION   OF   THE   FoOT. 

This  operation  was  designed  by  Wladimiroff  in  1872,  and 
independently  by  Mickulicz  in  1881. 

It  consists  in  the  removal  of  the  soft  parts  covering  the 
heel,  together  with  the  os  calcis  and  astragahis,  and  in  bringing 
into  contact  the  sawn  surfaces  of  the  tibia  and  fibula  on  the 
one  hand,  and  those  of  the  cuboid  and  scaphoid  on  the  other. 
The  foot  is  thus  fixed  in  the  position  of  talipes  equinus,  and 
the  patient  walks  upon  the  balls  and  phalanges  of  the  toes. 
The  whole  of  the  skin  covering  the  heel  is  of  necessity  lost. 

The  best  account  of  the  operation,  together  with  an 
abstract  of  nineteen  cases,  and  a  full  bibliography,  is  given 
by  Dr.  C.  Fenger  (Journ.  of  the  Amer.  Med.  Assoc,  January 
29th,  1887). 

Operation.— The  foot  must  be  brought  well  beyond  the 
end  of  the  table,  and,  the  knee  having  been  bent,  the  foot  is 
turned  upon  its  side.  Or  the  patient  may  be  more  con- 
veniently placed  in  the  prone  position,  the  heel  being  thus 
directed  upwards. 

The  same  instruments  are  required  as  are  used  in  Piro- 
goffs  operation,  with  the  addition  of  a  periosteal  elevator. 
The  following  are  the  steps  of  this  somewhat  complex 
procedure  : — 

1.  A  transverse  incision  is  made  across  the  sole  of  the 
foot,  from  the  tuberosity  of  the  scaphoid  to  a  point  a  little 
behind  the  base  of  the  fifth  metatarsal  bone.  From  the 
extremities  of  this  cut  an  incision  is  carried  obliquely  upwards 
and  backwards,  on  either  side  of  the  foot,  to  the  bases  of  the 
malleoli.  The  two  extremities  of  the  cut  are  finally  connected 
by  a  horizontal  incision  which  crosses  over  the  tendo  Achillis 
and  completes  the  wound  (Fig.  124,  E  F  g).  The  incision  is 
carried  weU  down  to  the  bone  at  all  parts.     The  plantar  vessels 


OSTEO-PLASTIG    RESECTION   OF   FOOT. 


457 


are  divided  at  the  inner  part  of  the  wound,  on  its  plantar 
aspect. 

2.  The  foot  is  now  flexed  to  its  utmost  upon  the  leg,  and 
while  in  this  position  the  ankle-joint  is  freely  opened  from 
behind,  the  tendo  Achillis  having  been  of  course  divided, 
togfether  Avith  all  the  ligaments. 

Disarticulation  at  the  ankle  is  effected  and  the  foot  still 
fiu'ther  flexed  upon  the  leg. 

3.  The  soft  parts  of  the  dorsum  are  now  separated  from  the 
astragalus  with  an  elevator,  the  instrument  travelling  from 
behind  forwards. 

This  may  be 
done  subperi- 
osteally,  so  as  to 
avoid  any  injury 
to  the  anterior 
tibial  artery  or 
the  extensor 
tendons. 

4.  The  cal- 
caneo  -  cuboid 
and  astragalo- 
scaphoid  joints 
are  opened  from  above,  and  the  whole  of  the  heel,  together 
with  the  OS  calcis  and  astragalus,  removed. 

5.  The  lower  ends  of  the  tibia  and  fibula  are  now  sawn 
through  horizontall}',  high  enough  up  to  just  clear  the  articular 
surface  of  the  former  (Fig.  124,  a  b).  The  joint-surfaces  of 
the  sc^aphoid  and  cuboid  are  removed  by  a  vertical  saw-cut 
(Fig.  124,  c  d). 

6.  The  two  cut  surfaces  of  bone  are  brought  together,  and 
are  retained  in  contact  by  sutures  of  kangaroo-tendon  or  of 
silver  wire  ;  the  divided  ends  of  the  post-tibial  nerve  are 
united  if  possible.  The  superficial  wound  is  closed  and  drained, 
and  the  foot — now  in  the  position  of  extreme  talipes  equinus — 
is  fixed  upon  a  special  splint,  and  secured  in  position  by  a 
plaster-of-Paris  dressing. 

The  soft  parts  on  the  dorsum  are  redundant,  and  are 
thrown  into  folds,  but  in  time  they  shrink  and  the  surface 
becomes  even.     The  limb,  if  adjusted  to  a  splint  in  the  first 


Fig.    124. — OSTEO-PLASTIC   EE'>LCTIOX    OF   TUT-    lOOl. 

A  B  and  c  D,  Saw-cuts  ;  e  f  g.  Skin  incisions. 


458 


OPERATIVE    SURGERY. 


instance,  should  be  fixed  in  plaster  of  Paris  as  soon  as  possible. 

When  the  patient  begins  to  walk,  a  special  boot  has  to  be  worn 

(Fig.  125),  so  as  to  maintain  the  parts  rigidly  in  the  position 

of  talipes  equiniis. 

It  is  claimed  that  osseous  union  takes  place  between  the  cut 

surfaces  of  bone.     The  parts  beyond  the  operation  area  are 

nourished  by  the  dorsahs  pedis 
artery  and  by  its  anastomoses 
with  the  plantar  vessels. 

As   a  result  of  the  operation 
the     hmb     is     usually    a    httle 


lengthened. 


Fig.  125. — ASPECT  OF  LIKE  AND 
INSTEtmENT  TO  BE  "WORN  APTEE 
OSTEO- PLASTIC   RESECTION  OF  THE 

FOOT.     {Brit.  Med.  Journ.,  May, 
1888.) 


Comment.  —  Dr.  Fenger  has 
collected  nineteen  examples  of 
this  procedure,  in  thirteen  of 
which  the  operation  was  per- 
formed for  tubercular  caries. 
Out  of  the  full  number  two 
died,  some  six  or  eight  months 
after  the  operation,  of  general 
tuberculosis  ;  twelve  made  a  good 
recovery  and  walked  with  more 
or  less  ease ;  in  five  a  failure 
followed,  with  the  result  that  in 
three  cases  amputation  of  the  leg  was  called  for. 

The  indications  given  for  the  procedure  are  the  following : — 
Extensive  injuries  of  the  heel  region ;  caries  of  the  os  calcis 
and  astragalus,  with  disease  of  the  neighbouring  joints ;  cases 
of  destructive  and  intractable  ulceration  of  the  skin  of  the 
heel ;  some  instances  of  cicatricial  contraction  of  the  foot,  with 
inconvenient  deformity. 

This  operation  is  still  on  its  trial,  and  has  been  subjected  to 
much  adverse  criticism. 

The  supporters  of  it  probably  lay  too  much  stress  upon  the 
importance  of  preserving  every  possible  scrap  of  the  foot.  It 
is  a  question  whether  the  patients  subjected  to  this  operation 
would  walk  better  than,  or  even  as  well  as,  those  who  had  had  the 
entire  foot  removed,  and  had  been  provided  with  a  good  artifir;ial 
limb.  The  present  operation  should  not  be  entertained  when 
the  integuments  of  the  heel  are  sound,  because  it  is  certainly 


OSTEO-PLASTIG    BE  SECTION    OF   FOOT.  459 

a  procedure  inferior  to  Syme's  amputation.  The  process  of 
recovery  is  very  slow ;  some  of  the  patients  were  unable  to 
walk  well  until  seven,  twelve,  or  fifteen  months  had  elapsed ; 
others,  on  the  other  hand,  could  walk  without  the  boot. 

Moreover,  the  operation,  to  be  successful,  requires  good 
powers  for  repair,  and  such  poAvers  are  not  always  to  be  ex- 
pected in  the  subjects  of  tubercular  caries.  The  oioeration 
requires  a  perfectly  sound  condition  of  the  integuments  of  the 
dorsum  of  the  foot — a  condition  well  adapted  for  a  supra- 
malleolar amputation  with  a  long  anterior  flap. 

The  operation  would  seem  to  be  best  suited  to  cases  of  in- 
tractable ulceration  of  the  heel,  to  cases  of  gunshot  injury,  and 
to  some  examples  of  inconvenient  deformity 


4&J 


CHAPTER    XXVIII. 

Amputation    of    the    Leg. 

Amputation  of  the  leg  was  at  one  time  performed  almost  ex- 
clusively at  the  "  place  of  election,"  i.e.,  at  a  point  a  hand's- 
breadth  below  the  line  of  the  knee-joint. 

At  this  point  the  bones  were  divided.  The  selection  of 
this  spot  was  determined  by  the  subsequent  needs  of  the 
patient.  The  only  prosthetic  apparatus  he  could  avail  himself 
of  was  the  "  box -leg  "  or  "  peg-leg."  With  this  appliance  the 
knee  was  maintained  bent,  and  the  weight  of  the  body  was 
supported  upon  the  tubercle  and  tuberosities  of  the  tibia. 
The  amputation  at  the  place  of  election  secured  this  point 
d'ajjpui,  and  at  the  same  time  left  no  inconveniently  long 
stump  projecting  backwards  from  the  peg-leg. 

The  great  improvements  effected  in  modern  times  in 
artificial  limbs,  and  in  the  apparatus  adopted  for  cases  of 
amputation,  have  entirely  disturbed  the  "  place  of  election." 
The  general  rule  in  present  operative  practice  is  to  remove  as 
little  of  the  limb  as  possible,  it  being  recognised  that  the 
danger  to  the  patient  increases — other  things  being  equal — 
with  the  height  of  the  amputation.  An  artificial  support  can 
be  adapted  to  the  stump  that  will  allow  the  limb  to  be  retained 
in  its  normal  position,  and  will  permit  the  movements  of 
the  knee-joint  to  be  still  made  use  of  Even  if  the  amputa- 
tion be  performed  at  the  old  place  of  election,  it  is  by  no  means 
necessary  that  the  weight  must  be  borne  upon  the  anterior 
surface  of  the  tibia.  In  an  amputation  at  so  high  a  level, 
an  artificial  limb  can  still  be  employed  which  will  enable  the 
patient  to  retain  the  use  of  the  knee-joint. 

It  comes  to  pass,  therefore,  that  in  amputations  of  the  leg 
the  stump  must  be  able  to  bear  pressure,  the  bones  must  be 
weU  covered,  and  the  cicatrix  should  not  be  terminal.      On 


AMPUTATION    OF   LEG.  '      461 

this  account  the  circular  method  is  in  no  way  adapted  for 
these  operations,  and  the  same  remark  applies  to  amputation 
by  lateral  flaps  of  equal  size.  In  both  these  procedures  the 
rosultmg  cicatrix  must  be  terminal  and  exposed  to  pressure. 

If  in  amputating  at  the  old  place  of  election  it  is  determined 
to  use  the  peg-leg,  and  to  forego  the  use  of  the  knee,  then  this 
question  of  pressure  upon  the  end  of  the  stump  ceases  to  be  of 
moment,  and  the  circular  amputation,  or  the  amputation  by 
equal  lateral  flaps,  may  be  carried  out.  It  may  certainly  be 
said  that  for  amputations  below  the  old  place  of  election  the 
two  last-named  methods  are  quite  unsuited. 

With  regard  to  the  jjlanning  of  flaps,  it  is  needless  to  point 
out  that  the  soft  parts  covering  the  front  of  the  limb  are  com- 
paratively scanty,  and  are  not  particularly  well  supplied  with 
blood.  On  the  posterior  aspect  of  the  limb  are  extensive 
muscular  layers  and  two  large  blood-vessels.  On  anatomical 
grounds  a  posterior  flap  is  to  be  preferred  to  an  anterior  one, 
inasmuch  as  it  affords  a  better  covering  to  the  bone,  is  better 
adapted  to  resist  pressure,  and  has  a  fuller  and  a  more  evenly 
distributed  blood-supply. 

In  any  case  in  which  the  major  flap  is  the  posterior 
one,  the  posterior  tibial  nerve  should  be  dissected  out,  so  that 
it  may  not  be  exposed  to  the  otherwise  inevitable  pressure. 
This  precaution  was  insisted  upon  by  Hey  many  years  ao-o. 

A  large  anterior  flap  must  of  necessity  be  composed  to 
some  extent  of  skin  alone. 

In  the  upper  third  of  the  limb  a  very  excellent  flap  may 
be  cut  from  the  antero-external  aspect  of  the  leg,  which  has 
not  this  disadvantage.  This  is  the  large  external  flap  (page  479), 
which  includes  in  its  whole  length  the  anterior  tibial  arter}'. 

In  general  terms,  it  may  be  said  that  the  cutting  of  flaps 
by  transfixion  in  these  amputations  is  to  be  condemned.  This 
especially  applies  to  the  formation  of  the  posterior  flap.  A 
flap  so  cut  is  apt  to  be  uncertainly  fashioned  as  regards  its 
shape  and  thickness.  The  main  blood-vessels  of  the  calf  can 
scarcely  escape  unnecessaril}^  high  division.  i\Ioreover,  the 
very  unequal  manner  in  which  the  flexor  muscles  at  the  back 
of  the  leg  retract  on  division  renders  it  desirable  that  these 
muscular  planes  should  be  divided  with  precision. 

Before  sawing  the  bones,  the  interosseous  membrane  should 


462        •  OPERATIVE    SURGERY. 

be  carefully  divided  with  a  scalpel,  so  that  it  may  not  he 
grazed  by  the  saA\^ 

In  "  dissecting  up  "  flaps — i.e.,  in  separating  the  soft  parts 
they  contain  from  the  hones  and  the  interosseous  membrane — 
the  forefinger  and  the  handle  of  the  scalpel  should  be  freely 
used  in  the  place  of  the  cutting  blade. 

General  directions  as  to  the  mode  of  sawing  the  bone  of  the 
leg  are  given  on  page  482. 

Stumps  left  after  amputation  of  the  leg  are  very  apt  to 
become  conical,  especially  in  the  lower  part  of  the  limb. 

The  amputations  may  be  dealt  with  in  three  regions  : — 

A.  Supra-malleolar  amputation. 

B.  Amputation  through  the  middle  of  the  leg. 
c.  Amputation  at  the  "  place  of  election." 

A. — SUPRA-MALLEOLAR  AMPUTATION. 

Anatomical  Points. — These  amputations  concern  the 
lower  third  of  the  leg.  In  this  region  the  tibia  has  become 
more  rounded,  and  its  sharp  crest  has  entirely  disappeared. 
The  bone  is  expanded  transversely  at  the  level  of  the  base  of 
the  malleolus,  while  just  above  that  point  the  shaft  is  com- 
paratively slender. 

The  interosseous  space  is  disappearing,  and  before  the  ankle 
is  reached  the  tibia  and  fibula  are  in  close  contact. 

The  upper  band  of  the  anterior  annular  ligament  passes 
transversely  across  the  hmb,  above  the  level  of  the  malleoli,  is 
attached  to  both  the  tibia  and  fibula,  and  binds  down  the 
vertical  portion  of  the  extensor  tendons.  The  whole  region  is 
surrounded  by  tendons. 

To  the  lower  third  of  the  tibia  no  muscular  fibres  are  at- 
tached ;  therefore  the  tibial  side  of  afla,p  is  easily  separated.  To 
the  corresponding  part  of  the  fibula  arc  attached  portions  of  the 
muscular  origin  of  the  extensor  communis  digitorum,  extensor 
proprius  pollicis  and  peroneus  tertius  in  front,  of  the  peroneus 
brevis  externally,  and  of  the  flexor  longus  pollicis  behind. 

When  the  lower  third  of  the  limb  is  reached,  the 
gastrocnemius  and  soleus  have  joined,  while  the  muscular 
fibres  of  the  latter  muscle  are  rapidly  disappearing  into  the 
tendon.  The  other  tendons  about  this  segment  of  the  leg,  viz., 
those  of  the  tibialis  anticus,  tibialis  posticus,  peroneus  longus, 


SUPBA-MALLEOLAR  AMPUTATION.  463 

and  flexor  longus  digitoriim,  are  still  accompanied  by  muscular 
fibre.  The  tendons  most  free  of  muscular  tissue  are  those  of 
the  tibialis  anticus  and  peroneus  longus.  The  largest  muscular 
mass  near  the  ankle  belongs  to  the  flexor  longus  pollicis. 

The  anterior  tibial  artery  lies  in  front  of  the  tibia,  between 
the  tibiahs  anticus  and  extensor  communis  digitorum,  and  is 
crossed  obliquely  by  the  extensor  proprius  pollicis.  The  nerve 
is  placed  to  its  outer  side.  The  peroneal  artery  lies  close  to  the 
inner  border  of  the  fibula,  under  cover  of  the  flexor  longus 
pollicis,  and  just  above  the  malleolus  breaks  up  into  the  anterior 
and  posterior  peroneal  vessels.  The  posterior  tibial  artery  is 
comparatively  superficial  at  the  lower  third  of  the  leg ;  it  lies 
behind  the  inner  part  of  the  tibia,  and  skirts  the  outer  border 
of  the  flexor  lonofus  digitorum  muscle.  To  its  outer  side  lies 
the  posterior  tibial  nerve. 

The  long  saphenous  vein  passes  in  front  of  the  inner 
malleolus,  while  behind  the  external  malleolus  runs  the  short 
saphenous  vein. 

Methods. — The  following  methods  of  operating  will  be 
described : — 

1.  Oblique  elliptical  incision  (Guyon's  operation). 

2.  Modified  circular. 

3.  Oblique  elliptical  incision  (Duval's  operation). 

4.  Large  posterior  flap. 

5.  Teale's  amputation. 

Instruments. — A  small  amputation-knife  with  a  blade  of 
about  five  inches  ;  a  stout,  somewhat  narrow,  knife,  with  a  blade 
four  inches  long,  a  narrow  but  rounded  point,  and  a  large, 
strong  handle  (this  would  be  a  modified  resection  knife, 
and  is  required  for  Guyon's  operation ;  it  may  also  be  used  to 
separate  the  anterior  or  posterior  flap  from  the  bones  in  the 
other  amputations) ;  a  scalpel,  an  amputating-saw,  retractors, 
.  pressure  forceps,  artery  and  dissecting  forceps,  scissors,  etc. 

Position. — The  patient  lies  on  the  back,  with  the  foot  and 
lower  part  of  the  leg  projecting  well  beyond  the  end  of  the 
table.  The  surgeon  should  stand  to  the  outer  side  of  the  right 
limb,  and  to  the  inner  side  of  the  left.  In  performing  Guyon's 
amputation,  he  may  more  conveniently  take  up  his  position  at 
the  foot  of  the  table. 

One  assistant  stands  or  sits  facing  the  end  of  the  table. 


464 


OFEEATIVE    SURGE  BY. 


He  holds  the  foot,  and  manipulates  it  when  required,  during 
the  operation.  A  second  assistant  stands  facing  the  surgeon, 
and  attends  to  the  sponging,  etc. 

1.  Amputation  by  Oblique  Elliptical  Incision  (Gwyon's 
Ojyeration). — This  operation  a  little  resembles  Syme's  ampu- 
tation. It  allows  the  terminal  part  of  the  stump  to  be  covered 
by  the  tissues  of  the  back  of  the  heel,  and  involves  a  low 
division  of  the  bones.  It  can  rightly  be  termed  a  supra- 
malleolar amputation,  and  the  me- 
dullary canals  of  the  bones  are  not 
opened  b}''  the  saw. 

The  incision  commences  in  front, 
at  a  point  just  opposite  the  line  of 
the  ankle-joint,  and  ends  behind,  over 
the  summit  of  the  curve  of  the  heel. 
Between  these  points  the  incision 
sweeps  in  a  slightly  curved  manner 
from  above  downwards  across  the 
ankle.  The  cut  on  the  inner  side 
just  skirts  the  malleolus ;  on  the 
outer  side  it  passes  a  little  in  front 
of  the  corresponding  process  (Fig. 
126,  A). 

In  making  the  skin  incision  the 
surgeon  holds  the  foot  in  his  left 
hand,  and  manipulates  it  himself 

In  dealing  with  the  right  foot  it 
is  convenient  to  turn  the  foot  in- 
wards, and  to  commence  the  incision  at  the  heel  and  on  the 
outer  side. 

The  knife  then  traverses  the  external  side  of  the  limb,  and 
reaches  the  front  of  the  ankle.  The  foot  being  now  turned 
outwards,  the  mcision  is  carried  back  along  the  inner  side  of 
the  foot  to  the  heel  again.  On  the  left  side,  the  foot  having 
been  turned  inwards,  the  incision  may  be  commenced  in  front, 
and  be  carried  back  to  the  heel  along  the  outer  aspect  of  the 
limlj.  When  the  foot  has  been  turned  outwards,  the  ellipse  is 
comi)letcd  by  drawing  the  knife  from  the  heel  to  the  startuig- 
point  across  the  inner  side  of  the  ankle. 

The  first  incision  involves  merely  the  skin  and  the  sub- 


Fig.  126. — A,  Guyon's  supra- 
malleolar am]mtation ;  (a), 
saw-line  for  that  operation  ; 
B,  Duval's  supra-malleolar 
amputation;  (i)  saw-line  for 
this  operation. 


SUPBA-MALLEOLAB  AMPUTATION. 


465 


cutaneous  tissues.  The  surgeon  then  proceeds  to  dissect  up  the 
posterior  or  heel  flap.  This  must  inchide  all  the  soft  parts 
down  to  the  bone.  An  exception  may  be  made  of  the  peronei 
tendons  behind  the  external  malleolus.  They  need  not  be 
disturbed,  and  should  not  be  divided  until  a  level  above  the 
ankle-joint  has  been  reached.  Great  care  must  be  taken 
of  the  vessels  on  the  inner  side  of  the  os  calcis.  The  tendo 
Achillis  is  cut,  and  the  soft  parts  are  cleared  away  from  the 
bones  of  the  leg  up  to  a  point  about  two 
inches  above  the  tips  of  the  malleoli.  It  is 
convenient  to  sit  in  order  to  dissect  up  the 
posterior  flap. 

The  foot  should  now  be  extended,  and  the 
anterior  incision  carried  well  down  to  the 
bone,  care  being  taken  to  avoid  opening  the 
ankle-joint.  The  soft  parts  on  the  front  of 
the  leg  are  dissected  up  to  the  level  named. 

Retractors  having  been  adjusted,  the 
bones  are  divided  horizontally  well  above  the 
bases  of  the  malleoli. 

The  posterior  tibial  nerve  should  be  dis- 
sected out  and  removed. 

Hcemorrhage. — The  anterior  tibial  artery 
is  divided  near  the  anterior  border  of  the 
tibia.  The  posterior  tibial  vessel  is  cut  at 
the  inner  side  of  the  heel  flap,  and  the  ter- 
mination of  the  peroneal  at  the  outer  side. 

In  the  soft  parts  in  front  of  the  outer  malleolus  the  anterior 
peroneal  is  divided. 

CoTYinfient. — This  amputation  would  of  course  not  be  per- 
formed should  Syme's  operation  be  possible.  The  stump, 
when  the  margins  of  the  wound  have  been  united  by  suture, 
looks  a  Httle  clumsy. 

The  cicatrix,  however,  is  transverse,  is  well  on  the  anterior 
aspect  of  the  limb,  and  is  removed  from  the  line  of  pressure. 
A  good  stump  is  ultimately  provided,  one  valuable  feature  of 
which  consists  in  the  covering  furnished  by  the  integuments 
of  the  heel  (Fig  127> 

The  amputation  permits  of  a  very  low  division  of  the 
bones. 


Fig.     127.  —  STUMP 

LEFT  BY  GUYON'S 
ST7PRA-MALLE0LAE 
AMPUTATION. 

{After  Farabeuf.) 


466  OPERATIVE    SURGERY. 

2.  Modified  Circular  Amputation.  —  This  method  has 
been  recommended  in  this  region,  and  appears  to  have  been 
frequently  practised  by  French  surgeons.  Such  an  amputation 
is  that  known  as  Lenoir's  (Fig.  131,  a).  A  circular  incision 
is  made  into  the  soft  parts  just  above  the  malleoli,  and  about 
1^  inch,  or  4  cm.,  below  the  point  at  which  the  bones  are 
to  be  sawn.  This  is  joined  by  a  vertical  cut,  in  the  middle  of 
the  leg,  Avhich  is  carried  up  to  the  level  of  the  saw-Hne  along 
to  the  mner  side  of  the  tibial  crest. 

The  anterior  skin  flaps — i.e.,  the  flaps  (such  as  they  are) 
on  either  side  of  the  vertical  wound — are  dissected  up  as  far 
as  possible.  The  circular  incision  is  not  disturbed  after  the 
integuments  have  been  well  freed.  All  the  soft  parts  down  to 
the  bone  are  now  divided  by  one  sweep  of  the  knife,  held  very 
obliquely. 

The  operation  is  easy  to  perform,  but  is  not  to  be  recom- 
mended. The  skin  covering  of  the  bones  is  a  great  source 
of  weakness ;  the  cicatrix  occupies  the  end  of  the  limb,  and 
is  exposed  to  pressure;  and  a  conical  stump  can  hardly  be 
avoided. 

Dupuytren  employed  a  circular  incision  just  above  the 
malleoli,  so  inclined  that  the  posterior  part  of  the  circle 
touched  the  insertion  of  the  tendo  Achillis,  while  the  anterior 
segment  crossed  the  limb  a  little  above  the  ankle-joint. 

Two  vertical  incisions  Avere  then  made,  one  on  the  front 
and  the  other  on  the  back  of  the  Hmb,  and  both  in  the 
median  line.     In  this  manner  two  lateral  flaps  were  formed. 

The  objections  urged  against  the  last  operation  apply 
equally  to  this  procedure. 

3.  Amputation  by  Oblique  Elliptical  Incision  (Mar- 
cellin  Duval's  Operation). — In  this  operation  the  bone  is 
divided  much  higher  up  than  in  Guyon's  amputation.  An 
oblique  elliptical  incision  is  made,  around  the  limb  above  the 
malleoli. 

The  incision  is  thus  planned : — The  point  at  which  the 
bones  are  to  be  divided  having  been  determined  upon,  the 
lower  or  posterior  extremity  of  the  eUipse  should  reach  a 
distance  below  that  point  equal  to  not  less  than  the  antero- 
posterior diameter  of  the  limb  at  the  level  of  the  saw-cut.  The 
hi.f'her,  or  anterior,  extremity  of  the  ellipse  should  be  no  less 


8UPBA-MALLE0LAR  AMPUTATION.  4i&l 

distance  below  the  proposed  saw-cut  than  that  equal  to  half 
the  antero-posterior  diameter  (Fig.  126,  b). 

In  effecting  these  measurements  allowance  must  be  made 
for  retraction  of  the  skin.  Thus — as  Farabeuf  says — if  the 
antero-posterior  diameter  at  the  level  of  the  saw-cut  be  8  cm., 
then  the  posterior  end  of  the  incision  should  reach  a  point 
12  cm.  below  that  level,  while  the  anterior  extremity  of  the 
skin-cut  should  be  6  cm.  below  the  same.  The  incision  is 
inclined  at  about  45  degrees. 

The  position  of  the  surgeon  has  been  already  indicated. 
An  assistant  manipulates  the  foot.  On  both  the  right  and 
the  left  limb  the  wound  can  be  more  conveniently  commenced 
at  the  posterior  aspect  of  the  leg. 

The  first  incision  includes  the  skin  only.  The  skin  is  well 
separated,  and  is  allowed  to  retract.  The  knife — kept  close 
to  the  margin  of  the  retracted  skin — is  now  made  to  traverse 
all  the  soft  parts  down  to  the  bone.  The  tendo  Achillis  is 
cut  early.  The  tissues,  on  both  the  anterior  and  posterior 
aspects  of  the  limb,  are  dissected  up  to  a  little  beyond  the 
level  of  the  proposed  saw-cut. 

This  dissection  is  by  no  means  easy,  especially  on  the 
peroneal  side  of  the  limb.  The  bones  must  be  well  bared. 
In  dissecting  up  the  posterior  tissues  the  surgeon  may  sit 
and  have  the  leg  well  raised  in  front  of  him.  After  the  bones 
have  been  divided  the  posterior  tibial  nerve  is  dissected  out. 
Some  surgeons  advise  that  the  tendo  AchilHs  be  connected, 
by  deep  sutures,  with  the  divided  ends  of  the  anterior  muscles. 

Hcemorrhar/e. — The  anterior  tibial  artery  is  divided  in 
front  of  the  tibia ;  the  posterior  tibial  behind  the  base  of 
the  inner  malleolus ;  the  posterior  peroneal  behind  the  outer 
malleolus,  and  the  anterior  peroneal  in  the  posterior  flap 
opposite  the  lower  end  of  the  interosseous  space. 

Comment. — This  operation  would  be  very  difficult  should 
there  be  any  matting  together  of  the  soft  parts  from  chronic 
disease. 

The  stump  looks  a  little  clumsy  at  first.  The  cicatrix  is 
transverse,  and  is  placed  upon  the  anterior  aspect  of  the 
stump  (Fig.  128).  It  is  nearer  the  extremity  of  the  stump 
than  is  the  scar  in  Guyon's  amputation. 

4.  Amputation  by  a  Large  Posterior  Flap. — This  opera- 

E    E    li 


468 


OPERATIVE    SUBGEBY. 


tion,  which  is  accredited  to  Tavignot  in  1840,  has  been 
much  modified  from  time  to  time.  The  present  account 
follows  the  directions  given  by  Farabeuf.  Two  flaps "  are 
made,  the  posterior  being  the  larger.  The  length  of  the 
posterior  flap,  when  completed,  is  equal  to  that  of  half  the 
circumference  of  the  limb  at  the  saw-line.  This  is  after 
retraction  has  been  allowed  for.  As  the  flap  may  be  con- 
sidered to  lose  about  one-third  of  its  length  by  retraction,  the 
posterior  flap,  as  originally  marked  out  on 
the  skin,  will  to  this  extent  exceed  in  length 
the  measurement  given. 

The  anterior  flap  is  about  one-fourth  of 
the  posterior.  The  flaps  may  be  conveniently 
fashioned  as  shown  in  Fig.  133,  A.  The 
posterior  flap  reaches,  so  far  as  its  skin  limit 
is  concerned,  to  about  the  insertion  of  the 
tendo  Achillis.  The  internal  vertical  in- 
cision which  limits  it  descends  in  front  of 
the  inner  border  of  the  tibia.  The  external 
vertical  incision  lies  behind  the  fibula. 

(1)  The  surgeon  stands  in  the  position 
already  indicated.  On  the  right  side  the 
foot  should  be  turned  well  out,  and  the  inner 
vertical  incision  made  from  above  down- 
wards to  the  level  of  the  insertion  of  the 
tendo  Achillis.  The  foot  being  now  turned 
inwards,  the  external  vertical  incision  is  made  in  like 
manner  from  above  downwards,  and  meets  the  companion 
cut  at  the  tendo  AchiUis  insertion.  On  the  left  Hmb  the  foot 
may  at  first  be  turned  inwards,  and  the  cutting  of  the  flap 
be  commenced  on  the  outer  side.  The  incision  should  involve 
the  skin  only,  and  should  be  so  made  that  the  integuments 
can  retract  well  all  round.  The  tendo  Achillis  is  now  divided. 
(2)  The  next  step  in  the  operation  must  be  carefully 
performed.  The  limb  having  been  well  turned  upon  its  outer 
side,  an  incision  is  made  through  the  exposed  muscles  down  to 
the  tibia.  This  deep  incision,  which  follows  the  hne  of  tho 
skin-cut,  may  be  about  two  inches  in  length.  It  should  be 
de<-'poned  by  separating  the  muscles  from  tho  tibia.  The  limb 
is  then  turned  upon  its  inner  side,  and  a  like  incision  is  made 


Fig.  128.  —  sruMP 
left  by  m.  du- 
val's  supra-mal- 
leolae  amputa- 
TION.   {Farabeuf.) 


TE ALE'S  AMPUTATION.  469 

down  to  the  fibula,  and  the  wound  is  deepened,  so  tar  as  it 
extends,  by  separating  the  muscles  from  that  bone.  In  this 
manner  two  deep  lateral  slits  or  gaps  (fentes)  are  made  down 
to  the  bones  through  the  whole  thickness  of  the  posterior  flap. 
The  thumb  having  been  thrust  into  one  of  these  gaps,  and 
the  forefinger  into  the  other,  the  soft  parts  at  the  back  of  the 
limb  can  then  be  pinched  up  by  the  surgeon's  left  hand.  The 
foot  is  maintained  in  the  flexed  position,  while  the  posterior 
flap  is  completed  by  cutting  from  without  inwards  (as  shown 
in  Fig.  132).  The  posterior  flap  so  fashioned  leaves  the  bones 
and  the  interosseous  membrane  practically  free. 

(3)  The  anterior  flap  is  now  cut.  The  soft  parts  are 
divided  down  to  the  bones  as  soon  as  the  skin  has  fully 
retracted,  and  are  then  dissected  up  so  as  to  leave  the  bones 
and  the  interosseous  membrane  on  this  aspect  of  the  Hmb 
practically  bare  also. 

(4)  Retractors  having  been  adjusted  and  the  interosseous 
membrane  divided,  the  tibia  and  fibula  are  sawn  through; 
the  posterior  tibial  nerve  is  dissected  out  and  removed. 

Deep  sutures  may  be  passed  between  the  muscular  masses 
upon  the  front  and  back  of  the  limb. 

Hcemorrkage. — The  anterior  tibial  artery  is  cut  in  the 
anterior  flap,  in  front  of  the  interosseous  space.  The  posterior 
tibial  and  peroneal  vessels  are  divided  posteriorly ;  the  former 
about  the  middle  of  the  flap,  and  the  latter  in  a  line  with  the 
fibula.  The  internal  saphenous  vein  may  possibly  be  cut  in 
making  the  internal  vertical  incision.  It  usually,  however, 
lies  wholly  in  the  posterior  flap,  at  the  lower  and  inner  angle 
of  which  it  is  found  divided. 

Comment. — The  stump  has  prominent  "  ears,"  and  at  first 
may  look  a  little  clumsy.  It  generally,  however,  turns  out 
admirably.  The  bones  are  well  covered  by  the  thick  posterior 
flap,  and  the  cicatrix,  which  is  transverse,  is  well  removed 
from  the  Hne  of  pressure. 

5.  Teale's  Amputation  by  a  Large  Anterior  Flap. — 
The  lower  third  of  the  leg  is  considered  to  be  a  particularly 
favourable  position  for  the  practice  of  Teale's  amputation. 

The  general  plan  of  the  operation  has  been  already 
described  (page  296).  The  circumference  of  the  limb  having 
been  taken  at  the  level  of  the  future  saw-line,  the  anterior 


470 


OPERATIVE    SUEGERY. 


flap  is  so  marked  out  that  in  its  length,  as  well  as  in  its 
breadth,  it  shall  be  equal  to  one-half  the  circumference. 

The  posterior  flap  should  be  one-fourth  the  length  of  the 
anterior  flap,  and  will  include  the  remaining  half  of  the 
circumference  of  the  limb  (Fig.  129). 

The  lateral  incisions  follow  the  margins  of  the  tibia  and 


Fig.  129. — teale's  amputation  of  the  leg. 

fibula.  The  limits  of  the  greater  flap  may  be  conveniently 
marked  out  upon  the  skin  with  ink. 

The  position  of  the  surgeon  and  his  assistants  has  been 
already  indicated. 

The  anterior  flap  may  be  commenced  on  the  inner  side  of 
the  limb  on  the  right  side,  and  on  the  outer  aspect  on  the 
left  side.  The  two  lateral  incisions  should  be  made  by  cut- 
ting from  above  downwards.  It  should  be  remembered  that 
the  anterior  flap  is  rectangular,  and  of  the  same  size  all  the 
way  down. 

The  incision  marking  out  the  great  flap  should  at  first 
concern  the  skin  only.  The  incision  is  then  deepened  down 
to  the  bones.  The  foot  should  be  extended  while  the  tendons 
at  the  end  of  the  flap  are  being  divided. 

The  anterior  flap  should  contain  all  the  soft  parts  on  the 
front  of  the  limb.  These  should  be  carefully  dissected  up 
from  the  bones  and  the  interosseous  membrane.  The  flap 
contains  the  anteiior  tibial  artery  in  its  whole  length. 


•"^'^-'^ 


TE ALE'S  AMPUTATIOX.  471 

The  posterior  flap  may  be  completed  by  a  simple  vigorous 
transverse  cut  across  the  back  of  the  limb  from  the  skin  to 
the  bones. 

The  foot  should  be  flexed  during  this  manceuvre.  The 
flaps  having  been  retracted  to  a  httle  beyond  the  saw-hne,  the 
retractors  are  applied,  the  interosseous  membrane  is  divided, 
and  the  bones  are  sawn  throuo-h. 

When  the  wound  has  been  closed  by  sutures,  the  stump 
has  the  appearance  shown  in  Fig.  130. 

Hcemorrhage. — The  anterior  tibial  vessels  are  divided  at 
the   free   lower   end 
of  the  anterior  flap,         •-^>^^-...,.....,.-.:,,. ......-.-:..■-  ....  -r^-.-^.r..,-^,  ,  ^i.,,,^,,^,^,^^^^^ 

and     at    about     its  ^\ 

middle.      The     pos-  '    *  ^  i 

terior  tibial  artery  is 

found  cut  upon  the 

face  of  the  posterior  ^~"' '"""'"-^ 

_  11*  Fig-    130. — STTJMP   LEFT   AFTEE  TEAIE  S    AMPUTATIOX 

nap  and  towards  its  of  the  leg. 

inner  side,  the  vessel 

lying  between  the  margins  of  the  flexor  longus  digitorum  and 

flexor  longus  pollicis. 

The  peroneal  vessels  are  divided  on  the  outer  part  of  this 
flap,  close  to  the  fibula,  and  under  cover  of  the  flexor  longus 
pollicis. 

The  long  saphenous  vein  will  be  found  in  the  anterior 
flap,  the  short  saphenous  in  the  posterior  flap. 

Comment. — Inasmuch  as  the  leg  narrows  towards  the 
ankle,  it  is  easy,  by  following  the  general  lines  of  the  limb, 
to  make  the  anterior  flap  too  narrow  below. 

It  is  claimed  for  this  amputation  that  the  bones  are 
covered  by  a  flap  which  does  not  contain  too  much  muscular 
tissue,  and  which  possesses  an  artery  in  its  entire  length. 
It  is  also  urged  that  the  cicatrix  is  placed  at  the  back  of  the 
stump,  and  is  not  exposed  to  pressure. 

The  operation  has  not  been  received  Avith  so  much  favour 
in  other  countries  as  it  undoubtedly  possesses  in  England. 

The  main  bone  to  be  covered  at  the  end  of  the  stump  is 
the  tibia.  The  anterior  flap  affords  this  bone  in  large  part  a 
covering  of  skin  only,  and  the  integuments  on  the  front  of 
the  leg  are  usually  quite  thin.     The  anterior  flap,  moreover, 


472  OFEBATIVE    SURGERY. 

is  of  very  unequal  thickness,  containing  skin  onl}^  at  its  inner 
part,  and  a  substantial  mass  of  muscle  at  its  outer  side.  It 
has  been  pointed  out  that  a  portion  of  the  anterior  flap  may 
be  cut  from  the  dorsum  of  the  foot ;  but  the  tissues  of  that 
part  are  ill  adapted  to  form  the  free  end  of  a  principal  flap. 
The  skin  there  is  very  thin,  the  subcutaneous  tissue  is  scanty, 
and  the  soft  parts  beneath  are  represented  almost  exclusively 
by  tendons.  Teale's  amputation  makes  a  great  demand  upon 
the  structures  on  the  anterior  aspect  of  the  limb,  and  involves 
a  comparatively  high  division  of  the  bones. 

Of  the  four  operations  above  described,  it  may  be  said  in 
general  terms  that  Guyon's  amputation  is  the  best  when  a  low 
division  of  the  bones  is  possible,  and  that  the  most  suitable 
mode  of  amputating  the  leg  in  its  lower  third  is  by  means  of 
the  long  posterior  flap. 

Should  the  tissues  at  the  posterior  aspect  of  the  limb  be 
much  damaged,  Teale's  operation  may  be  conveniently  carried 
out. 

B. AMPUTATION  THROUGH  THE  MIDDLE  OF  THE  LEG. 

Anatomical  Points. — At  the  middle  of  the  leg  the  limb  is 
very  muscular,  the  mass  of  muscles  in  the  calf  being  con- 
siderable. The  main  muscle  in  front  of  the  interosseous 
membrane  at  this  level  is  the  tibiahs  anticus.  The  extensor 
communis  digitorum  is  of  fair  size,  the  extensor  proprius 
pollicis  is  as  yet  small.  All  these  muscles  are  attached  to 
the  bones.  The  anterior  tibial  artery  lies  in  front  of  the  inter- 
osseous membrane,  midway  between  the  two  bones,  and 
is  very  deeply  placed.  At  the  back  of  the  limb  the  main 
muscular  mass  belongs  to  the  soleus.  The  muscle  is  free 
except  at  its  inner  side,  where  it  is  still  attached  to  the 
internal  border  of  the  tibia.  It  is  capable  therefore  of  some 
retraction  when  divided.  The  plantarLs  tendon  is  free.  The 
gastrocnemius  at  this  level  is  still  muscular.  On  section  its 
bulk  is  seen  to  be  scarcely  equal  to  a  third  of  the  bulk  of 
the  soleus.  It  is  quite  free  from  bony  attachment,  and  can 
therefore  retract  readily  when  divided.  The  freedom  of  the 
gastrocnemius  and  soleus  muscles  is  of  primary  importance 
in  the  execution  of  Henry  Lee's  operation. 

The  remaining  muscles  at  the  back  of  the  limb  are  all 


AMPUTATION  OF  LEG.  473 

attached  to  tlie  bones,  and  are  not  therefore  capable  of  re- 
traction. Of  these,  the  tibiahs  posticus  is  the  largest;  the 
flexor  longus  digitorum  is  of  fair  size  ;  while  the  flexor  longus 
pollicis  is  as  yet  small. 

The  peroneal  artery  lies  close  to  the  fibula,  under  cover  of 
the  last-named  muscle.  The  posterior  tibial  vessels  he  in 
the  groove  between  the  tibialis  posticus  and  the  flexor  longus 
digitorum.  At  the  outer  side  of  the  hmb  are  the  two  peronei 
muscles,  both  attached  to  the  tibula.  The  peroneus  longus  at 
this  level  is  large,  the  peroneus  brevis  very  small 

With  regard  to  the  operations  which  may  be  performed  at 
the  middle  of  the  leg,  reasons  have  been  already  given  for 
condemning  the  circular  amputation  and  the  cutting  of  a 
posterior  flap  by  transfixion  (page  461). 

Teale's  operation  is  sometimes  advised  in  this  position. 
The  objections  which  have  been  urged  against  that  amputation 
in  the  lower  third  of  the  leg  apply  equally  to  this  section  of 
the  limb.  The  anterior  flap  is  of  considerable  length,  and  the 
bones  have  to  be  divided  at  an  unnecessarily  high  level.  The 
operation  may  be  carried  out  when  the  soft  parts  at  the  back 
of  the  Hmb  have  been  extensively  destroyed. 

The  two  procedures  best  adapted  for  this  region  are  the 
following : — 

1.  Amputation  by  a  Large  Posterior  Flap  {Heys  Opera- 
tion). 

Instruments. — An  amputating-knife  with  a  blade  about 
five  inches  in  length ;  a  stout  scalpel ;  an  amputating-saw ; 
retractors  (the  linen  retractor  used  to  protect  the  parts  during 
the  sawing  of  the  bones  may  have  three  tails,  the  central  and 
narrower  shp  being  passed  through  the  interosseous  space) ; 
pressure  forceps ;  artery  and  dissecting  forceps ;  a  periosteal 
elevator ;  scissors,  etc. 

Position. — The  patient  hes  upon  the  back,  with  the  leg 
and  knee  beyond  the  end  of  the  table.  In  dealing  with  the 
right  limb,  the  surgeon  stands  to  the  outer  side  of  the  leg ;  in 
dealing  with  the  left  limb,  to  the  inner  side.  One  assistant 
stands  or  sits  facing  the  end  of  the  table.  He  holds  the  foot 
and  leg,  and  manipulates  it  during  the  operation.  A  second 
assistant  stands  facing  the  surgeon  and  to  the  left  of  the 
patient,  and  attends  to  the  sponging,  etc. 


474 


OPERATIVE    SURGEUY. 


Operation. — Hey's  operation  is  described  in  his  "  Practical 
Observations"  (3rd  edition,  1814,  page  526).  The  procedure 
here  detailed  is  a  slight  modification  of  Hey's  method.      Hey 

cut  the  posterior  flap  by  trans- 
fixion, and  made  a  slightly  shorter 
anterior  flap. 

The  circumference  of  the  limb  at 
the  saw-line  having  been  noted,  the 
posterior  flap  is  so  made  that  its  length 
and  breadth  are  equal  to  a  third  of 
that  measurement — i.e.,  are  equal  to 
the  diameter  of  the  limb. 

The  anterior  flap  is  about  a 
third  of  the  length  of  the  posterior 
one.  The  large  posterior  flap  is  U- 
shaped.  The  main  incisions  are 
commenced  about  one  inch  below  the 
point  at  which  the  bones  are  divided. 
The  inner  limb  of  the  U  of  the 
posterior  flap  is  just  behind  the  in- 
ternal border  of  the  tibia,  while  the 
outer  limb  of  the  U  runs  posterior 
to  the  peronei  muscles  (Fig.  131,  b). 
These  muscles  are  consequently 
found  divided  in  the  anterior  flap. 

(1)  The  operation  is  commenced 
by  cutting  the  large  flap. 

On  the  right  side  the  limb  is 
turned  upon  its  outer  surface  {i.e., 
with  that  surface  looking  down- 
wards), the  knee  is  flexed,  and  the 
inner  vertical  incision  is  made  from 
above  downwards.  The  inner  seg- 
ment of  the  bend  of  the  U  is  then 
completed.  The  leg  is  now  turned 
upon  its  inner  side,  and  the  outer 
vertical  incision  is  made  by  cutting  from  above  downwards. 
In  finishing  it,  the  bend  of  the  U,  the  terminal  part  of  the  flap, 
is  completed  (Fig.  131,  b).  On  the  left  leg  the  limb  may 
be  first  turned  upon  its   inner   side   {i.e.,  with   that  surface 


Fig.  131. 
A,  Modified  circular  supra-mal- 
leolar  amputation  :  (a)  saw- 
line  of  same  :  13,  Hey's  am- 
l>utation :  {b)  saw-line  of 
same  ;  C,  Circular  amputation 
at  "the  place  of  election":  (c) 
saw-line  of  same  ;  D,  Gritti's 
operation. 


AMPUTATION  OF  LEG.  475 

looking  downwards),  and  the  operation  be  conniienced  by 
cutting  the  outer  vertical  incision. 

The  incisions  thus  made  concern  the  skin  only,  and  the 
integuments  are  well  freed  along  all  parts  of  the  cut. 

(2)  The  leg  is  now  flexed  upon  the  thigh,  and  the  knee 
turned  outwards  so  as  to  expose  the  calf.  When  in  this 
position,  and  while  the  foot  is  flexed,  the  gastrocnemius  muscle 
is  picked  up  between  the  fingers  and  thumb  and  is  divided 
transversely  at  the  level  of  the  retracted  skin. 

(8)  Two  short,  deep,  vertical  incisions  are  now  made  fi*om 
above  downwards  through  the  soft  parts  at  either  margin  of 
the  flap.  These  incisions  extend  to  the  bone :  the  inner 
direct  to  the  tibia,  the  outer  to  the  fibula  behind  the  peronei 
muscles. 

Into  the  gaps  thus  made  the  thumb  and  fingers  of  the  left 
hand  are  inserted,  and  the  muscles  of  the  calf,  being  firmly 
grasped,  are  lifted  up  from  the  bones.     {See  Fig.  132.) 

The  muscles  are  now  carefully  separated  from  the  bones 
along  these  two  short  lateral  incisions  with  a  stout  scalpel 
until  the  middle  of  the  flap  is  entirely  free,  and  the  thumb 
and  forefinger  can  be  made  to  meet  between  the  deep  muscles 
and  the  bones.  These  muscles  and  the  vessels  they  carry 
with  them  are  finally  divided  at  their  lower  parts  by  a  vigorous 
transverse  cut.  To  effect  this,  the  amputating-knife  is  intro- 
duced betw^een  the  separated  muscles  and  the  bones,  and  is 
made  to  cut  from  within  outwards.  The  posterior  flap  is  now 
quite  free  below,  and  the  soft  parts  above  are  cleared  away  from 
the  tibia  and  fibula  and  intervening  membrane  until  the  level 
of  the  saw-cut  is  reached. 

(4)  The  anterior  flajD  is  made  by  passing  the  knife  in 
a  curved  manner  across  the  face  of  the  limb.  The  incision 
at  first  involves  the  skin  only.  When  retraction  has  taken 
place,  the  muscles  are  cleanly  divided  doAvn  to  the  bones. 
These  muscles  are  then  dissected  up  as  far  as  the  level  of  the 
future  saw-cut,  the  interosseous  membrane  being  thus  bared 
in  front  as  well  as  behind. 

(5)  Retractors  having  been  applied,  and  the  interosseous 
membrane  divided  transversel}^  the  bones  are  sawn  through. 
The  periosteum  may  be  separated  from  the  lower  end  of  the 
tibia. 


476 


OPERATIVE    SURGERY. 


TTie  prominent  projection  of  tlie  anterior  border  of  the 
tibia  should  be  removed  with  the  saw  in  the  manner  described 
on  page  483.     {See  Fig.  137.) 

The  posterior  tibial  nerve  is  dissected  out  and  removed. 

Hcemorrhage. — The  anterior  tibial  artery  is  divided  at  the 
free  end  of  the  anterior  flap,  the  posterior  tibial  and  peroneal 
vessels  at  the  free  margin  of  the  posterior  flap.  The  position 
of  these  vessels  has  been  already  indicated. 


Fig.    132. — MODE    OF    DIYTDING    THE  TISSUES   IN  THE  AMPUTATION  BY  A  LAEGE 
POSTEEIOE  FLAP. 


2.  Amputation  by  Large  Posterior  Flap  (Henry  Lee's 
Operation). 

An  account  of  this  operation  is  given  in  the  Medico- 
Chirurgical  Transactions  (vol.  xlviii.,  page  195). 

The  instruments  required,  and  the  position  of  the  patient 
and  operator,  are  the  same  as  in  the  previous  amputation. 

The  same  order  may  be  observed  in  making  the  incisions. 

The  flaps  are  measured  and  fashioned,  so  far  as  the  skin 
incisions  are  concerned,  precisely  upon  the  lines  of  Teale's 
operation,  with  the  difference  that  the  main  flap  is  upon  the 
posterior  instead  of  upon  the  anterior  surface  of  the  limb. 
The  principal  flap,  moreover,  instead  of  containing  all  the  soft 
parts  covering  the  bones,  carries  with  it  only  the  superficial 


AMPUTATION  OF  LEG.  477 

flexor  muscles  of  the  calf.  Both  flaps  are  rectangular.  The 
anterior  flap  is  one-fourth  the  length  of  its  fellow  (Fig. 
143,  b).  The  relation  of  the  incisions  to  the  saw-line  is  the 
same  as  in  Teale's  method.  Both  flaps  are  marked  out  with 
the  knife,  the  incisions  involving  at  first  the  integuments 
only.  The  anterior  flap  is  the  first  to  be  completed.  The 
subsequent  steps  are  thus  described  by  Mr.  Lee : — 

"  When  the  skin  has  become  somewhat  retracted  by  its 
natural  elasticity,  an  incision  is  carried  through  the  parts  in 
front  of  the  tibia,  interosseous  membrane,  and  fibula.  The 
whole  of  the  parts  thus  divided  are  separated  close  to  the 
periosteum  and  interosseous  membrane,  and  are  reflected 
upwards  to  a  level  with  the  upper  extremities  of  the  first 
longitudinal  incisions. 

"  The  deeper  structures  at  the  back  of  the  leg  are  then 
freely  divided  in  the  situation  of  the  lower  transverse  incision. 
The  conjoined  gastrocnemius  and  soleus  muscles  are  separated 
from  the  subjacent  parts,  and  are  reflected  as  high  as  the 
anterior  flap.  This  part  of  the  operation  is  performed  with 
the  greatest  facility  on  account  of  the  loose  attachments  of 
these  muscles,  especially  at  the  lower  part  of  the  leg. 

"The  deeper  layer  of  muscles,  together  with  the  large 
vessels  and  nerves,  is  divided  as  high  as  the  incisions  Avill 
permit,  and  the  bones  sawn  through  in  the  same  situation." 

The  prominent  projection  of  the  anterior  border  of  the  tibia 
should  be  removed  with  the  saw.     (See  page  483 ;  Fig.  137.) 

The  posterior  tibial  nerve  should  be  dissected  out. 

The  position  of  the  three  principal  arteries  divided  has 
been  already  mentioned. 

Comment. — Both  of  these  operations  are  excellent.  The 
bones  are  well  covered;  the  cicatrix  is  transverse,  is  upon 
the  anterior  aspect  of  the  stump,  and  is  well  removed  from 
pressure. 

The  posterior  flap  in  Hey's  amputation  is  shorter  than 
in  Lee's  operation.  In  the  former  its  length  is  equal  to 
a  third  of  the  circumference  of  the  limb;  in  the  latter,  to 
one-half.  Provided  that  the  conditions  are  the  same,  it  will 
be  seen  that  the  second  operation  involves  a  greater  sacrifice 
of  parts  than  the  first ;  in  other  words,  Hey's  amputation  can 
be  performed  lower  down. 


478  OPERATIVE    SURGERY. 

The  procedure  advised  by  Lee  is  well  adapted  for  very 
muscular  limbs,  and  for  cases  where  the  deep  muscles  of  the 
calf  have  become  matted  together  or  damaged  by  disease  or 
injury. 

Hey's  operation  is,  on  the  other  hand,  well  suited  to  the 
majority  of  cases,  and  especially  to  limbs  of  moderate  or 
scanty  muscular  development. 

Of  the  two  operations,  Lee's  is  undoubtedly  the  more  easy 
to  perform. 

C. — AMPUTATION   AT  THE   "PLACE   OF   ELECTION." 

Anatomical  Points. — The  term  "place  of  election"  refers 
to  the  spot  at  which  the  bones  are  divided.  This  point  is 
about  a  hand's-breadth  below  the  knee-joint,  and  is  about,  or 
a  little  above,  the  great  nutrient  foramen  of  the  tibia.  The 
tibia  is  here  still  of  good  size,  the  cancellous  tissue  is  con- 
siderable, but  the  medullary  canal  has  commenced. 

The  skin  covering  the  upper  third  of  the  leg  is  a  little 
coarse,  is  not  very  mobile,  and  does  not  retract  so  extensively 
when  divided  as  it  does  lower  down  in  the  limb. 

A  transverse  section  of  the  leg  at  the  "place  of  election" 
shows  that  the  main  muscular  masses  on  the  antero-external 
aspect  belong  to  the  tibialis  anticus  and  the  peroneus  longus. 
The  extensor  communis  digitorum  is  still  a  very  small  muscle. 
The  peroneus  brevis  and  the  extensor  longus  pollicis  do  not 
reach  the  saw-line,  but  are  found  in  an  external  flap. 

At  the  back  of  the  limb  the  gastrocnemius  forms  a  very 
large  mass  of  muscle — so  large  as  to  be  nearly  equal  to  the 
rest  of  the  muscular  tissue  which  lies  behind  the  bones  and 
interosseous  membrane. 

The  soleus  is — at  this  level — divided  at  about  its  largest 
part.  The  tibialis  posticus  is  of  fair  size ;  the  flexor  longus 
digitorum  appears  as  a  mere  muscular  fragment.  The  flexor 
longnis  pollicis  lies  below  the  level  of  the  "  place  of  election." 
The  lowest  fibres  of  the  popliteus  are  divided  in  the  section  as 
they  adhere  to  the  posterior  surface  of  the  tibia. 

In  separating  or  "  dissecting  up  "  a  flap,  it  must  be  observed 
that  the  only  muscles  free  are  the  gastrocnemius  and  plan- 
taris.  AU  the  others  are  attached  to  the  bones  or  interosseous 
membrane. 


AMPUTATION  OF  LEG.  479 

The  anterior  tibial  artery  at  the  present  level  lies  deeply 
upon  the  face  of  the  interosseous  membrane,  and  close  to  the 
fibula.     The  anterior  tibial  nerve  is  to  its  outer  side. 

The  posterior  tibial  and  peroneal  arteries  are  found  lying 
upon  the  tibialis  posticus  and  occupying  the  same  level,  the 
latter  vessel  having  but  just  arisen  from  the  trunk.  These 
vessels  are  located  about  midway  between  the  two  bones. 

The  posterior  tibial  nerve  is  very  close  to  the  artery  of  the 
same  name,  but  is  placed  just  behind  it  and  to  its  inner 
side. 

The  following  are  the  met  hods  described  : — 

1.  Large  external  flap  (Farabeuf  s  operation). 

2.  Circular  method. 

3.  Equal  lateral  flaps. 

4.  Large  posterior  flap. 

1.  Amputation  by  Large  External  Flap  (Farabeuf s 
Operation). — An  amputation  in  this  part  of  the  leg  by  an  ex- 
ternal flap  has  been  devised  and  carried  out  by  Sedillot  and 
others. 

Farabeuf  has,  however,  so  far  modified  the  operation  that 
he  has  practically  designed  a  new  procedure.  He  has  pointed 
out  the  importance  of  preserving  the  anterior  tibial  artery  in 
the  whole  length  of  the  external  flap,  and  has  shown  that  if 
this  flap  be  cut  by  transfixion  the  vessel  cannot  escape 
damage. 

The  present  method  may  claim  to  be  a  very  substantial 
improvement  upon  previous  operations,  and  to  form  a  valuable 
addition  to  the  resources  of  the  surgeon. 

Insfruraents. — An  amputating-knife  with  a  blade  from  five 
to  six  inches  in  length.  A  stout  scalpel.  An  amputating-saw. 
A  periosteal  elevator.  Retractors.  Six  pressure  forceps. 
Artery  and  dissecting  forceps.     Scissors,  etc. 

Position. — The  patient  lies  upon  the  back,  and  is  so 
placed  that  the  middle  of  the  thigh  rests  upon  the  edge  of  the 
table.  The  sound  limb  is  secured  out  of  the  range  of  the 
operation. 

In  operating  upon  the  right  leg,  the  surgeon  stands 
throughout  on  the  outer  side  of  the  limb.  In  amputating  the 
left  leg,  he  should  stand  at  the  end  of  the  hmb,  and  a  little 
to  the  outer  side  of  it,   while  making   the  preliminary  skin 


480 


OPERATIVE    SUEGEBY. 


31 


incisions.     While  dissecting  up  the  flap  and  completing  the 
operation,  he  should  stand  to  the  inner  side  of  the  limb. 

One  assistant  is  placed  at  the  end  of  the  limb,  to  manipulate 
the  foot  and  leg.  The  second  assist- 
ant stands  ujjon  the  opposite  side 
of  the  limb  to  the  sursfeon,  whom  he 
faces. 

Operation. — The  external  flap  is 
U-shaped.  Its  length  is  equal  to 
that  of  the  diameter  of  the  limb  at 
the  level  of  the  future  saw-line — i.e., 
is  equivalent  to  one-third  of  the 
circumference  of  the  leg  at  the  same 
level  (Fig.  133,  b). 

The  anterior  limb  of  the  U  is 
commenced  opposite  to  the  saw-line, 
and  in  passing  down  the  leg  runs 
parallel  with  and  just  to  the  inner 
side  of  the  anterior  border  of  the 
tibia. 

The  posterior  limb  of  the  U  fol- 
lows a  line  on  the  back  of  the  calf 
diametrically  opposite  to  the  anterior 
hmb.  The  posterior  incision  ends, 
however,  above,  at  a  point  about  1| 
inch  below  the  commencement  of 
the  anterior  limb  of  the  U. 

1.  The  operation  is  commenced 
by  marking  out  the  external  flap  by 
a  skin  incision. 

In  the  case  of  both  the  right 
and  the  left  legs,  the  knee  should 
be  flexed  and  the  limb  turned  upon 
its  inner  side — i.e.,  so  turned  that  its 
outer  aspect  is  well  exposed  to  the 
surgeon.  The  position  of  the  operator  while  making  the  skin 
incisions  has  been  alluded  to.  On  the  right  side  the  incision 
may  be  commenced  in  front,  and  may  be  completed  in  one 
sweep,  the  anterior  wound  being  thus  made  from  above  down- 
wards and  the  posterior  from  below  upwards.     In  the  case  of 


Fig.  133. 
A,  Amputation  of  lower  iiart  of 
leg  by  long  posterior  flap  ;  B, 
Amputation  at  "  the  place  of 
election"  by  large  external  flap 
(Farabeuf's  operation)  ;  c, 
Garden's  amputation  ;  D,  Lis- 
ter's modification  of  the  same. 


AMPUTATION  OF  LEG. 


4n 


the  left  limb,  both  of  the  vertical  incisions  can  be  more  con- 
veniently made  by  cutting  from  above  downwards,  and  can 
be  subsequently  joined  by  the  terminal  curved  incision. 

2.  The  next  step  in  the  operation  is  to  free  the  skin  along 
the  whole  length  of  the  incision,  so  that  it  may  retract.  The 
integuments  are  merely  freed,  not  dissected  up. 

3.  The  limb  being  turned  outwards,  the  knife  is  passed 
across  the  inner  side  of  the  leg,  from  the  upper  end  of  the 
posterior  incision  to  a  point  on  the  anterior  cut  about 
1^  inch  below  its  commencement  (Fig.  133,  b).     This  incision 


rig.   134. — MODE     OF   CXJTTING     THE    FLAP    IN     THE     AMPUTATION-  AT  "  THE  PLACE   OF 
ELECTION  "    BY   A   LAEGE   EXTERNAL   FLAP.       (Farabeuf.) 


is  slightly  curved,  and  involves  the  skin  only.  The  integuments 
are  lightly  freed  along  the  line  of  the  incision. 

4.  The  limb  being  again  turned  with  its  inner  surface 
downwards,  the  operator  proceeds  to  dissect  up  the  great  flap, 
which  should  contain  all  the  soft  parts  down  to  the  bones. 

The  flap  is  separated  along  the  anterior  limb  of  the  U 
incision  by  cutting  from  above  downwards  down  to  the  bone 
along  the  outer  side  of  the  anterior  border  of  the  tibia.  The 
fingers  of  the  left  hand  are  thrust  into  the  gap  so  made,  and 
the  tibialis  anticus  is  separated  from  the  bone.  When  the 
muscle  is  sufficiently  separated,  it  is  cut  obliquely  from  above 
downwards  and  outwards,  so  that  the  section  of  the  muscle 
will  be  thin  when  the  margin  of  the  skin  is  reached 
(Fig.  134). 

The  whole  of  the  soft  parts  involved  in  the  external  flap 


482 


OPERATIVE    SURGERY. 


are  dissected  up  from  tlic  bones  and  interosseous  membrane. 
In  etfecting  this  the  linger  and  the  handle  of  a  scalpel  are  used 
more  freely  than  the  knife.  The  muscles  should  be  cut 
obliquely  at  their  lower  extremities,  so  that  the  section  of 
muscle  close  to  the  free  margin  of  the  skin — i.e.,  at  the  bend 
of  the  U — shall  be  quite  thin.  The  anterior  tibial  artery 
is  divided  at  the  free  end  of  the  flap  in  making  one  of  these 
oblique  sections  of  the  muscles  (Fig.  138). 

In  dissecting  up  the  soft  parts,  great  care  must  be  taken 
not  to  dissect  the  flap  up  too  far.    If  this  be  done,  it  is  possible 


Fig.  135. — METHOD  OF      Fig.   136.— ilLIilOD  OF  SAW- 
SAWING  THE  TIBIA.  ING  THE  BONES  OF  THE  LEG. 


Fig.    137. — IIETHOD  OF  SAW- 
ING THE  BONES  OP  THE  LEG. 


to  reach  the  spot  where  the  anterior  tibial  artery  is  piercing 
the  interosseous  membrane,  and  to  actually  divide  the  vessel 
at  that  spot. 

The  future  of  the  operation  depends  upon  the  integrity  ot 
this  artery. 

5.  The  soft  parts  included  in  the  small  inner  flap  may  now 
be  cut  by  transfixion  at  the  level  of  the  retracted  skin.  The 
muscular  tissue  so  divided  must  be  in  the  next  place  separated 
from  the  bones  up  to  the  level  of  the  saw-line.  The  bones  and 
interosseous  membrane  should  be  bared.  The  retractors  are 
now  applied  and  the  bones  sawn  through. 

6.  The  manner  in  Avhich  the  hones  are  sawn  is  of  some 
importance,  especially  as  the  prominent  anterior  border  of  the 
tibia  is  apt  to  project  into  the  anterior  wound  when  the  flaps 
have  been  adjusted.  The  remarks  now  to  be  made  apply  to 
all  amputations  in  this  region. 


AMPUTATION  OF  LEG.  483 

The  interosseous  membrane  having  been  incised,  the 
periosteum  covering  the  tibia  is  divided  by  a  circular  cut. 
This  circular  cut  is  joined  from  above  by  two  lateral  vertical 
incisions  through  the  investing  membrane.  The  two  flaps — 
anterior  and  posterior — of  periosteum  thus  marked  out  should 
be  separated  from  the  bone  by  an  elevator.  If  preferred,  these 
flaps  may  be  dissected  up  from  the  bone  with  the  deepest 
layers  of  muscle ;  or,  on  the  other  hand,  the  periosteum  on 
the  posterior  surface  of  the  tibia  may  be  ignored,  and  only  the 
anterior  segment  preserved.  Some  surgeons  strip  up  the 
periosteum  from  the  fibula  also. 

The  periosteum  is  retracted  to  a  point  just  above  the  saw- 
line.  The  surgeon  stands  in  the  same  position — i.e.,  to  the 
outer  side  of  the  right  leg  and  to  the  inner  side  of  the  left — 
and  divides  the  fibula  first.  The  Hmb  is  still  so  placed  that 
the  external  surface  is  uppermost.  In  sawing  the  left  fibula, 
the  point  of  the  saw  is  directed  downwards,  towards  the  floor. 
In  dividing  the  right  bone,  the  point  of  the  instrument  is 
directed  upwards,  towards  the  ceiling.  The  fibula  should  be 
divided  about  1  cm.  above  the  tibia,  and  the  saw  should  pass 
obliquely  from  above  downwards  and  inwards  (Fig.  136).  The 
saw  is  now  entered  upon  the  inner  surface  of  the  tibia,  above 
the  level  at  which  the  bone  is  to  be  divided.  The  instrument 
is  made  to  cut  downwards  and  outwards  for  a  certain  distance 
(Fig.  135,  a).  The  transverse  saw-cut  is  now  made  from  be- 
fore backwards  (Fig.  135,  b),  with  the  result  that  the  whole 
bone  is  divided,  the  piece  marked  out  by  the  first  saw-incision 
drops  off,  and  the  tibia  presents  a  sloping  surface  on  its  inner 
side  (Fig.  136). 

This  method  of  dividing  the  bones  is  adapted  to  the 
amputations  by  external  flap  or  by  two  lateral  flaps. 

In  the  case  of  amputation  by  antero-posterior  flaps  or  by 
the  circular  method,  the  fibula  may  be  cut  at  the  same  level 
as  the  tibia,  and  the  anterior  margin  of  the  tibia  should  then 
be  removed  by  a  sloping  saw-cut,  the  instrument  being  applied 
in  the  manner  just  detailed  (Figs.  135  and  137). 

The  periosteal  flap  or  flaps  having  been  adjusted  over  the 
divided  bone,  and  any  deep  sutures  having  been  inserted,  the 
operation  is  completed  by  closing  the  surface  wound. 

Hcemorrhage. — The  anterior  tibial  artery  is  divided  at  the 


484 


OPERA  TIVE    S  UR GER  Y. 


free  end  of  the  external  flap.  The  posterior  tibial  and  peroneal 
vessels  are  cut  close  together  and  lie  on  the  same  plane 
upon  the  face  of  the  inner  flap.     {See  page  479  and  Fig.  138.) 

Several  muscular  branches  will  require  ligature,  notably 
the  sural  arteries  connected  with  the  gastrocnemius  muscle, 
and  the  large  branch  from  the  posterior  tibial  artery  to  the 
soleus.  The  nutrient  artery  of  the  tibia  will  be  divided  at  or 
about  its  entrance  into  the  bone. 

Comment. — An  excellent  stump  results  from  this  operation- 
The  cicatrix  comes  upon  its  inner  side  and  is  well  removed 
from  pressure.     The  bones  are  admirably  covered,  and,  if  the 

operation  be  carefully  carried 
out,  the  vitality  of  the  great 
flap  is  ensured  (Fig.  139). 

I  believe  this  to  be  the 
best  operation  for  this  seg- 
ment of  the  leg.  I  have 
performed  it  in  several  cases 
which  were  by  no  means  well 
adapted  for  recovery  from 
any  amputation,  and  have 
been  exceedingly  pleased 
with  the  results.  These 
cases  were  examples  of  am- 
putation of  the  limb  m  aged 
and  broken-down  men  for 
intractable  ulcers  of  the 
lower  part  of  the  leg. 

The  stump  that  results  is 
sufficiently  long  to  allow  of 
such  an  artificial  leg  being 
worn  as  will  still  permit  the  movements  of  the  knee  to  be 
executed. 

In  selecting  a  method  of  amputation  at  this  level,  con- 
siderable weight  must  attach  to  the  intention  of  the  surgeon 
with  regard  to  the  artificial  support  that  is  to  be  worn. 

If  the  use  of  the  knee-joint  is  to  be  retained,  then  a  stump 
must  be  fashioned  that  can  bear  pressure  upon  its  extremity. 

If,  on  the  other  hand,  the  knee-joint  is  to  be  kept  per- 
manently flexed,  and  the  weight  of  the  body  is  to  be  borne 


Fig.  138. — APPEAEANOE  OF  THE  STTTMP  AFTER 
THE  AMPUTATION  OF  THE  LEO  AT  "THE 
PLACE     OF    election"    BY   A    LAEGE     EX- 

TBENAL  FLAP.     {Farabeuf.) 


AMPUTATION  OF  LEG. 


485 


upon  tlie  tuberosity  and  tubercle  of  the  bent  tibia,  then  the 
coverings  of  the  stump  and  the  position  of  the  cicatrix  are 
matters  of  comparatively  little  moment. 

The  operation  next  described  involves  a  terminal  cicatrix, 
and  a  not  too  well-covered  tibia.     It  is,  however,  a  convenient 
and  sound  procedure  if  the  patient  is  to  wear 
a  peg-leg  or  box-leg,  and  is  to  surrender  the 
use  of  the  knee-joint. 

2.  Amputation  by  the  Circular  Method. 
— The  same  instruments  are  required  as 
in  the  last  operation.  The  position  of  the 
surgeon  and  his  assistants  is  the  same, 
with  the  exception  that  the  operator,  in 
dealing  with  the  left  limb,  stands  through- 
out on  the  inner  side  of  the  les:. 

The  circular  skin-incision  should  be 
made  at  a  distance  below  the  saw-line  equal 
to  one-half  of  the  diameter  of  the  limb  at 
that  line  (Fig.  131,  c).  This  applies  to  the 
position  of  the  incision  when  retraction  of 
the  skin  has  been  allowed  for. 

For  example :  suppose  the  circumference 
of  the  limb  at  the  saw-line  to  be  15  inches, 
the  diameter  of  the  limb  will  be  repre- 
sented by  5  inches,  and  the  half-diameter  by  2J  inches,  or 
about  6  cm.  Retraction  of  the  skin  in  this  part  of  the 
limb  is  not  considerable.  To  allow  for  it,  the  circular  mark 
in  the  skin  might  be  commenced  about  3|  inches,  or  9  cm,, 
below  the  saw-line. 

The  posterior  segment  of  the  circular  incision  should  be  a 
little  higher  than  the  anterior  segment  (Fig.  131,  c).  The  tissues 
at  the  back  of  the  leg — notably  the  superficial  flexors — retract 
more  readily  than  do  the  soft  parts  upon  the  front  of  the 
limb.  If  the  circular  incision  be  quite  horizontal,  too  much 
skin  win  be  found  in  what  may  be  termed  the  posterior  flap. 

Operation. — 1.  The  limb  being  extended,  the  circular  skin- 
incision  is  made,  the  assistant  manipulating  the  limb  the 
while.  The  skin  is  lightly  freed  all  round  along  the  line  of 
the  incision. 

2.  The  skin  at  the  anterior  aspect  of  the  limb  is  separated 


Fiff.  139.  — STTTVPEE- 
SULTING  FK(iM  AM- 
PUTATION OF  THE 
LEG  AT  "  THK  PLACE 
OF  ELECTION  "by  A 
LARGE        EXTERNAL 

FLAP.     {Farabevf.) 


486  OPERATIVE    SUEGERY. 

from  the  soft  parts,  and  is  turned  up  as  a  cuff  until  the  soft 
parts  are  exposed  at  the  same  level  all  round  the  limb.  At 
the  sides  and  at  the  posterior  aspect  of  the  leg  the  skin — 
which  has  here  merely  undergone  its  natural  retraction — is 
not  disturbed. 

3.  The  knee  is  now  flexed,  and  the  leg  turned  outwards — 
i.e.,  with  its  outer  surface  directed  downwards.  The  calf 
being  well  exposed,  the  gastrocnemius  muscle  is  separated 
from  the  deep  flexors  with  the  fingers,  and  is  divided  trans- 
versely at  the  level  of  the  retracted  skin. 

4.  The  integuments  all  round  are  now  retracted  as  high 
as  possible,  the  gastrocnemius  muscle  being  separated  up 
with  the  skin  at  the  posterior  part  of  the  leg. 

This  retraction  and  separation  of  the  skin  should  not 
reach  so  high  as  the  future  saw-line. 

5.  The  soft  parts  are  now  divided  transversely  a  little 
below  the  saw-section.  The  division  is  commenced  in  front, 
and  the  limb  is  rotated  from  side  to  side  or  elevated  by  the 
assistant  as  the  surgeon  requires.  These  soft  parts  are  now 
separated  all  round  from  the  bones  and  the  interosseous 
membrane,  and  the  separation  is  carried  to  a  point  a  little 
above  the  saw-line. 

It  is  a  good  practice  to  divide  the  periosteum  of  the  tibia 
— and  possibly  also  of  the  fibula — horizontally  a  little  below 
the  future  saw-cut,  and  to  separate  the  periosteum  from  the 
bones,  together  with  the  soft  parts  immediately  covering  them. 

To  effect  this  the  interosseous  membrane  must  be  well 
divided,  and  the  periosteum  be  cut  laterally,  so  that  it  ma}'  be 
peeled  off  in  flaps. 

6.  Retractors  having  been  applied,  the  tibia  and  fibula 
nmst  now  be  sawn  in  the  manner  described  on  page  483.  The 
bones  after  division  will  present  the  appearance  shown  in 
Fig.  137. 

Deep  sutures  having  been  introduced,  and  the  flaps  of 
periosteum  adjusted,  the  operation  is  com2:)letcd  in  the  usual 
way. 

Comment. — A  good  well-rounded  stump  results  from  this 
method.  It  is  not  adapted  to  withstand  much  direct  pressure, 
since  the  scar  is  terminal.  If  the  weight  is  to  be  borne  upon 
the  bent  tibia,  then  the  stump  is  free  from  reproach. 


AMrUTATlUX  OF  LEG.  487 

The  value  of  the  circular  amputation  in  this  section  of 
the  lower  limb  has  been  already  discussed  (page  461). 

3.  Other  Methods  of  Amputation. — 1.  Amputation  by 
Equal  Lateral  Flaps. — The  general  shape  and  position  of  the 
flaps  are  shown  in  Fig.  140,  a.  The  flaps  are  semilunar  in  outline. 
The  anterior  median  incision  is  commenced  some  2  cm.  below 
the  future  saw-line,  and  is  carried  vertically  downwards  just  to 
the  outer  side  of  the  crest  or  anterior  border  of  the  tibia.  The 
posterior  incision  is  commenced  on  the  back  of  the  leg,  at  a 
point  diametrically  opposite  to  the  commencement  of  the 
anterior  incision. 

In  length  each  flap  should  slightly  exceed  the  half- 
diameter  of  the  limb  at  the  saw-line,  retraction  being  allowed 
for. 

Thus,  if  the  half-diameter  be  2h  inches,  or  6  cm.,  the 
lowest  curve  of  each  flap  may  reach  to  a  point  8|  inches,  or 
9  cm.,  below  the  saw-line.  When  the  skin  has  retracted,  each 
flap  will  be  found  to  be  about  2i  mches  in  length. 

The  flaps  are  dissected  up  as  skin-flaps. 

A  Httle  way  below  the  saw-hne  the  soft  parts  of  the  limb 
are  divided  transversely  down  to  the  bones.  They  are  then 
separated  from  the  bones,  and  the  operation  is  completed  as  in 
amputation  by  the  circular  method.  The  bones  are  divided 
as  shown  in  Fig.  137. 

This  operation  is  merely  a  modification  of  the  circular 
amputation.  It  is  easier  to  perform.  The  cicatrix  is  terminal, 
and  is  antero-posterior  instead  of  being  transverse. 

2.  Amputation  by  a  Large  Posterior  Flap,  as  described  in 
the  operation  upon  the  middle  of  the  leg  (page  476),  has  been 
performed  in  this  part  of  the  limb. 

3.  Teales  Amputation  has  also  been  carried  out  at  this 
level. 

It  will  be  seen  that  these  procedures,  especially  the  latter, 
involve  the  cutting  of  very  large  flaps  without  corresponding 
advantage. 

AFTER-TREATMEXT   OF   AMPUTATIONS   OF   THE   LEG. 

The  stump  should  not  be  covered  by  the  bed-clothes  (see 
page  69),  and  the  limb  should  be  slightly  raised  upon  a  firm 
pillow,  with  the  knee  a  little  bent. 


488  OPERATIVE    SURGERY. 

In  the  case  of  the  supra-malleolar  amputations,  and  in 
the  amputations  of  the  leg  by  a  large  posterior  flap,  the  limb 
should  be  supported  upon  a  back-splint.  This  splint  should 
be  apphed  in  the  manner  already  indicated  (page  309).  Care 
must  be  taken  that  the  wound  is  free  from  pressure.  In 
some  of  the  circular  amputations  also  the  splint  may  be  con- 
veniently applied. 

In  the  other  operations  the  hmb  may  be  lightly  secured 
to  the  pillow,  the  extremity  of  the  stump  projecting  some 
little  way  beyond  the  end  of  the  support,  as  in  Teale's  opera- 
tion above  the  ankle.  The  same  plan  may  be  adopted  after 
Farabeuf  s  amputation  at  the  place  of  election. 

The  sutures  should  not  be  removed  too  soon,  especially  in 
cases  where  a  posterior  muscular  flap  has  been  formed,  or 
where  a  single  flap  from  the  outer  side  of  the  Hmb  has  been 
fashioned,  or  where  the  circular  method  has  been  carried  out. 
After  the  sutures  are  removed  the  flaps  may  possibly  need  to 
be  supported  by  strapping. 

If  drainage-tubes  are  required,  they  should  be  introduced 
for  a  short  distance  only  at  the  angles  of  the  wound.  A  tube 
should  never  be  inserted  through  the  depths  of  the  wound 
from  one  side  of  the  stump  to  the  other.  They  should  be  re- 
moved at  the  earliest  possible  date. 


489 


CHAPTER    XXIX. 

Disarticulation  at  the  Knee-Joint. 

This  operation  appears  to  have  been  introduced  into  modern 
practice  by  Velpeau  in  1830,  and  to  have  been  first  per- 
formed in  England  in  1857  by  Mr.  S.  Lane  {Lancet,  voL  ii, 
1857). 

It  was  not  received  with  great  favour,  and  after  a  while 
feU  into  disrepute.  Not  a  few  surgeons  indeed  considered 
that  the  operation  was  unjustifiable,  and  should  never  be 
performed. 

The  objections  urged  against  it  were  these : — The  synovial 
pouches  which  were  left  upon  the  stump  suppurated  and 
formed  recesses  for  the  accumulation  of  pus.  The  bursse  about 
the  joint  gave  similar  trouble.  Pus  spread  dangerously  among 
the  loose  tissues  of  the  ham.  The  cartilage  covering  the 
condyles  of  the  femur  was  apt  to  become  necrosed  and  to  be 
exfoliated  by  a  very  tedious  process.  The  bone  not  infre- 
quently became  involved.  The  flaps  formed  were  disposed  to 
slough,  and  while  this  applied  especially  to  the  large  anterior 
flap,  it  could  also  be  frequently  urged  against  a  large  posterior 
flap.  Even  if  the  patient  survived  the  dangers  of  extensive 
and  prolonged  suppuration,  and  reached  the  time  when  the 
wound  had  healed,  the  resulting  stump  was  still  unsatisfactory 
It  was  as  a  rule  tender,  disposed  to  ulcerate,  send  unable  to 
bear  pressure. 

The  mortality  of  the  operation  was  considerable.  Panas, 
in  a  statistical  table  {Diet,  de  Med.  et  Chir.  Prat,  Art.,  Genou), 
showed  that  a  recovery  occurred  in  only  33  cases  out  of  a 
total  of  137  operations. 

Since  the  introduction  of  antiseptic  methods  for  treating 
wounds,  and  of  certain  improvements  in  the  details  of  the 
operation,  the  whole  aspect  of  the  question  has  become 
altered. 


490 


OPERATIVE    SUBGEBY. 


iB 


Flaps  can  now  be  made  that  do  not,  under  ordinary  con- 
ditions, slough.  The  operation  wound  may  heal  up  by  first 
intention,  or  after  only  a  very  moderate  degree  of  suppura- 
tion. Su23purative  inflammation  in  the 
relics  of  the  synovial  membrane  is  no 
longer  to  be  feared,  and  exfoliation  of 
the  cartilage  is  either  not  met  with 
at  all,  or  occurs  as  a  ver}^  limited  and 
quite  accidental  trouble.  The  once 
anxious  doubt  as  to  the  fate  of  the  ar- 
ticular cartilage  no  longer  disturbs  the 
operator's  mind.  It  is  no  longer  neces- 
sary to  further  complicate  a  serious 
operation  by  .scraping  away  synovial 
membrane  and  cutting  off  cartilage. 
The  patient  can  now  bear  the  weight 
of  his  body  upon  the  extremity  of  the 
stump. 

The  mortality  has  also  undergone 
a  substantial  improvement.  Ashhurst 
("  Encyclopaedia  of  Surgery,"  vol.  i., 
1882)  gives  the  statistics  of  794  ex- 
amples of  amputations  of  various  kinds, 
both  through  the  knee-joint  itseK  and 
through  the  femoral  condyles.  The 
mortality  is  47 '7  per  cent. 

Brj^ant,  in  an  account  of  30  dis- 
articulations at  the  knee-joint,  per- 
formed b}^  himself  between  the  years 
1868  and  1883,  demonstrates  a  mor- 
tality of  less  than  25  per  cent.  Indeed, 
among  19  cases  of  disarticulation  for 
disease,  only  one  death  is  recorded  as  directly  due  to  the 
operation  {Med.-Ghir.  Trans.,  vol.  Ixix.,  1886,  page  163). 

This  disarticulation  has  many  advantages  over  the  simpler 
and  more  brilliant-looking  amputations  through  or  above  the 
femoral  condyles.  There  is  less  shock,  and  less  of  the  limb  is 
removed.  The  section  of  the  tissues  of  the  limb  is  less,  and 
the  connective  tissue  planes  of  the  thigh  are  not  opened  up. 
Important  muscular  attachments  are  left   undisturbed,  and 


Fig.  140. — A,  Amputation 
at  "the  place  of  election" 
by  lateral  flaps  ;  B,  Dis- 
articulation at  the  knee 
by  long  anterior  flap. 


AMPUTATION  AT   THE   KNEE-JOINT.  491 

there  is  little  muscular  retraction.  The  cancellous  tissue  of 
the  feniur  is  not  exposed  by  the  saw. 

The  stump  is  an  excellent  one,  capable  of  great  mobility 
and  of  bearing  direct  pressure.  This  is  important  when  it  is 
remembered  that  very  few  indeed  of  the  stumps  resulting 
from  amputation  through  the  femur  Avill  bear  direct  pressure. 
Farabeuf,  writing  upon  this  point,  remarks  that,  so  far  as  he 
knows,  the  stumps  left  after  amputation  through  the  shaft 
of  the  femur  can  never  directly  transmit  the  weight  of  the 
body. 

Before  describing  individual  methods  of  procedure,  it  may 
be  said  that  in  every  case  it  is  essential  that  the  knee-joint  be 
free  from  disease.  In  no  instance  is  it  necessary  to  dissect  away 
the  remains  of  the  synovial  membrane,  nor  to  attempt  its 
destruction  by  scraping.  The  less  the  cartilage  is  disturbed, 
the  better  ;  and  the  practice  of  cutting  it  away  from  the  bone 
is  unnecessary  and  harmful. 

Both  the  patella  and  the  semilunar  cartilages  should  be 
left  undisturbed. 

By  leaving  the  patella  the  stump  is  rendered  firmer,  and 
its  rotundity  is  greatly  increased.  Moreover,  the  attachments 
of  the  quadriceps  are  not  disturbed,  and  the  muscular  strength 
of  the  stump  is  considerably  mcreased.  On  the  other  hand, 
by  dissecting  out  the  patella  much  damage  is  inflicted  upon 
the  anterior  flap.  Not  only  is  it  dangerously  thinned,  but  its 
blood-supply  is  further  curtailed.  It  has  never  been  shown 
that  any  evil  has  followed  the  retaining  of  the  patella. 

By  leaving  the  semilunar  cartilages  in  contact  with  the 
bone,  the  upper  part  of  the  synovial  capsule  is  held  down 
firmly  to  the  condyles  of  the  femur,  and  the  soft  parts  con- 
cerned are  kept  well  in  place.  Dr.  Brinton  advocated  the 
leaving  of  the  cartilages  in  the  stump  as  early  as  1872.  "  By 
thus  leaving  them  in  position,"  he  writes,  "  I  have  a  cap  fitted 
upon  the  end  of  the  femur,  which  preserves  all  the  fascial 
relations,  eventually  prevents  retraction,  and  guards  against 
the  projection  of  the  condyles."  Mr.  Bryant  endorses  this 
advice. 

Anatomical  Points. — The  skin  over  the  front  of  the  knee- 
joint  is  dense,  coarse,  and  movable,  and  well  supplied  with 
blood.     The   subcutaneous  tissues   are  scanty.      The  skin  is 


492  OPERATIVE    SURGERY. 

most  loose  in  the  position  of  extension.  AVlien  the  joint  is 
flexed,  the  integuments  are  drawn  tightly  over  the  patella. 
In  dissecting  up  an  anterior  skin-flap  therefore,  the  limb  is 
kept  extended. 

The  vessels  supplying  the  soft  parts  in  front  of  the  joint — 
the  parts  forming  the  large  anterior  flap — are  the  anastomotica 
magna,  the  four  articular  branches  of  the  popliteal,  and  the 
anterior  tibial  recurrent.  The  last-named  vessel  and  the  two 
lower  articular  arteries  are  divided  when  the  flap  is  cut.  The 
most  important  vessels  in  the  separated  flap  are  those  derived 
from  the  anastomotica  magna. 

The  inter-articular  line  is  easily  demonstrated.  The  crease 
in  the  skin  which  passes  transversely  across  the  ham  is  some 
way  above  the  line  of  the  knee-joint.  The  inner  condyle  of 
the  femur  is  much  more  prominent  than  the  external,  a  point 
to  be  borne  in  mind  in  fashioning  lateral  flaps.  The  tubercle 
of  the  tibia  and  the  head  of  the  fibula  are  nearly  upon  the 
same  level. 

The  synovial  membrane  of  the  knee-joint  extends  upwards 
as  a  cul-de-sac,  about  one  inch  above  the  upper  margin  of  the 
patella.  Above  this  pouch  is  a  bursa  between  the  femur  and 
the  quadriceps  tendon.  It  measures  about  one  inch  vertically. 
This  bursa  communicates  with  the  joint  in  some  seven  cases 
out  of  ten  in  children,  and  in  about  eight  cases  out  of  ten  in 
adults. 

The  upper  third  of  the  patellar  ligament  is  in  relation  with 
the  synovial  membrane. 

The  lower  end  of  the  patella  corresponds  roughly  to  the 
inter-articular  line,  when  the  knee  is  extended.  To  be  quite 
precise,  it  is  just  level  with  the  upper  margin  of  the  tibia. 

The  external  semilunar  cartilage  is  smaller,  rounder,  less 
firmly  attached,  and  more  movable  than  the  internal. 

At  the  inter-articular  line  the  popliteal  artery  is  descending 
vertically  behind  the  middle  of  the  joint  capsule,  upon  which 
it  rests.  It  terminates  on  a  level  with  the  lower  part  of  the 
tubercle  of  the  tibia.  At  the  level  of  the  knee-joint  the 
popliteal  vem  is  lying  behind  the  artery.  The  internal 
jX)plitoal  nerve  is  behind  the  vein,  and  a  little  to  its  outer 
side.  The  walls  of  the  vein  arc  so  dense  and  thick  that  on 
section  the  vessel  looks  almost  like  an  artery.     It  is  very 


AMPUTATION  AT   THE  KNEE-JOINT.  493 

closely  adherent  to  the  arterial  trunk.  The  internal  saphenous 
vein  passes  along  the  back  of  the  internal  condyle. 

The  upper  articular  arteries  run  transversely  outwards  and 
inwards  just  above  the  femoral  condyles.  The  articular 
vessels  below  the  knee  run  respectively  just  below  the  inner 
tuberosity  of  the  tibia  and  just  above  the  head  of  the  fibula. 
The  superior  external  and  inferior  internal  arteries  are  of  fair 
size.     The  others  are  quite  small. 

The  large  sural  arteries  arise  just  above  the  joint-line. 

The  following  methods  are  here  described : — 

1.  Disarticulation  by  lateral  flaps  (Stephen  Smith's 

operation). 

2.  Disarticulation    by    elliptical    incision    (Bauden's 

operation). 

3.  Disarticulation  by  long  anterior  flap. 

1.  Disarticulation  by  Lateral  Flaps  (Stephen  Smith's 
Operation). — This  operation,  known  usually  as  disarticulation 
by  "lateral  hooded  flaps,"  is  described  in  the  American 
Journal  of  Medical  Sciences,  January,  1870. 

The  flaps  consist  of  the  integuments  only,  the  posterior 
muscles  being  divided  transversely  about  the  level  of  the 
articulation. 

Instruments. — An  amputating-knife  with  a  blade  5  to 
6  inches  in  length  ;  a  stout  scalpel ;  six  pressure  forceps ;  artery 
and  dissecting  forceps  ;  retractors,  scissors,  etc. 

Position. — The  patient  lies  upon  the  back,  and  is  so  placed 
that  the  middle  of  the  thigh  rests  upon  the  lower  margin  of 
the  table.  The  sound  limb  is  secured  out  of  the  way.  The 
surgeon  stands  to  the  outer  side  of  the  right  leg,  to  the  inner 
side  of  the  left.  One  assistant,  placed  at  the  extremity  of  the 
limb,  holds  the  leg  and  manipulates  it  as  required.  The 
second  assistant  stands  facing  the  surgeon,  and  attends  to 
the  flaps,  the  sponging,  etc. 

Operation. — The  flaps  are  of  somewhat  semilunar  outline. 
The  incision  commences  in  front,  in  the  median  line,  about  one 
inch  below  the  tubercle  of  the  tibia.  It  is  carried  in  a  curved 
manner  across  the  most  prominent  part  of  the  outer  side  of  the 
leg,  and  is  then  made  to  slope  upwards  to  reach  the  middle 
line  at  the  posterior  aspect  of  the  Hmb.  It  terminates  as  a 
vertical  cut  opposite  the  centre  of  the  inter-articular  line. 


494 


OPERATIVE    SURGERY. 


A  second  incision  begins  at  the  same  point  on  the  front 
of  the  limb  as  the  first,  and  pursues  a  similar  direction  across 
the  inner  side  of  the  leg,  meeting  the  first  incision  at  the 
median  line  upon  the  posterior  aspect  of  the  extremity.  The 
inner  flap  should  be  a  little  fuller  than  the  outer,  in  order  to 
ensure  a  sufficient  covering  for  the  internal  condyle,  which  is 
longer  and  larger  than  the  external. 

The  outline  of  the  flaps  is  shown  in  Fig.  141,  a. 
1.  The  skin  incisions  on  both  the  right  and  the  left  leg 
are  more  conveniently  made  b}^  cutting  from  behind  forwards. 

The  knife  is  entered  at  the  posterior 
aspect  of  the  limb,  at  a  spot  opposite 
to  the  centre  of  the  inter-articular  line, 
and  is  drawn  forwards,  first  upon  one 
side  of  the  limb  and  then  upon  the 
other,  to  reach  the  point  of  meeting, 
one  inch  below  the  tubercle  of  the  tibia. 
While  the  outer  incision  is  being 
made  the  limb  is  rotated  iuAvards,  and 
vice  versa. 

The  knee-joint  should  be  extended 
during  the  cutting  of  the  flaps. 

2.  The  skin  is  freed  all  round,  and 
the  two  flaps  are  dissected  up.  They 
should  include  all  the  soft  parts  down 
to  the  tendons  and  muscles,  which  are 
well  laid  bare,  but  are  as  yet  left  un- 
cut. The  patellar  ligament  is  cut  as 
soon  as  it  is  reached,  being  divided 
against  the  tuberosity  of  the  tibia. 

The  flaps  are  retracted  to  the  level 
of  the  joint-line, 
now  made  along  the  extreme  upper 
This  incision,  which  is  transverse  and 
concerns  the  anterior  and  lateral  aspects  of  the  bone,  divides 
everything  down  to  the  bone,  including  the  ilio-tibial  band, 
the  tendons  of  the  sartorius,  gracilis,  semitendinosus  and  biceps 
muscles,  the  internal  and  external  lateral  ligaments,  and, 
lastly,  the  coronary  ligaments  attaching  the  semilunar 
cartilages.     The  knife,  indeed,  enters  the  joint  between  the 


Fig.  141.— A,  Stephen  Smith's 
disarticulation  at  the  knee  ; 
B,  Amputation  of  the  thigh 
by  lateral  flaps. 


3.  An   incision   is 
margin  of  the  tibia. 


AMPUTATION  AT   THE  IvNEE-JUlNT. 


49.^ 


upper  surface  of  the  tibia  and  these  cartilages,  and  it  is  in 
tliis  manner  that  the  articulation  is  opened.  In  dividing  the 
coronary  ligaments  the  knife  should  be  entered  at  the  sides  of 
the  joint  and  not  in  front. 

The  knee  is  now  Hexed,  and  the  two  crucial  ligaments  are 
carefully  divided  from  before  backwards. 

4  Nothing  remains  but   to  divide    by  a  vigorous  trans- 
verse cut  the  soft  parts  still  connecting  the  leg  with  the  thigh, 
viz.,  the  posterior  ligament  of  the  joint,  the  popliteal  vessels 
and  nerves,  the  popliteus  and  gastrocne- 
mius muscles,  and  the  semi-membranosus 
or  other  undivided  tendon  of  the  ham. 

Before  making  this  final  incision,  the 
assistant  who  is  retracting  the  flaps 
should  compress  the  popliteal  artery 
against  the  lower  end  of  the  femur. 

Bryant  advises  that  the  condyloid 
origins  of  the  gastrocnemius  should  be 
removed,  but  there  appears  to  be  no  need 
for  this  step. 

Hcemorrhcif/e. — The  popliteal  artery 
and  vein  are  the  only  \essels  of  any  size 
requu-ing  Hgature.  Ligatures  will  probably 
be  needed  for  the  sural  arteries,  the  azygos 
artery,  for  branches  of  the  superior  articular  vessels  (especially 
on  the  outer  side),  and  for  the  superficial  division  of  the  ana- 
stomoti'^a  magna  (on  the  inner  side  of  the  hmb). 

Comment. — This  operation  provides  an  excellent  and  com- 
plete covering  for  the  condyles  of  the  femur.  When  the  edges 
of  the  flaps  are  brought  together,  the  wound  looks  directly 
downwards  as  the  patient  lies  in  bed.  The  stump  therefore  is 
admirably  provided  for  in  the  matter  of  drainage. 

A  very  serviceable  extremity  results.  The  cicatrix  lies  in 
an  antero-posterior  direction  between  the  condyles,  and  in 
process  of  time  occupies  the  inter-condyloid  notch.  Into  this 
depression  it  sinks,  and  the  prominent  condyles  serve  to  eftec- 
tually  protect  it  from  pressure.  It  will  be  seen,  moreover,  that 
the  scar  is  in  time  drawn  towards  the  posterior  aspect  of  the 
Umb,  and  is  thus  further  protected  from  pressure  when  an 
artificial  leg  is  worn  (Fig.  142). 


Fig.     142. — THE     STT7MP 

■  AFTEE  STEPHEN  smith's 

AMPUTATION      AT      THE 

KNEE  -  JOINT.      {After 

Bryant.) 


496 


OPERATIVE    SURGERY. 


Pick's  Operation.— Mi\  Pick  (Med.  Soc.  Trans.,  1884,  page 
134)  has  devised  a  very  similar  operation  to  the  present.  Two 
lateral  skin-flaps  are  made.  "  The  incision  is  commenced  at  the 
upper  border  of  the  patella,  and  is  carried  down  the  middle 
line  of  the  limb  as  low  as  the  tubercle  of  the  tibia.     It  is 

then  curved  outwards  over  the  outer 
side  of  the  leg  to  the  back,  and  is 
carried  upwards  along  the  middle 
line  to  a  point  corresponding  to  the 
commencement  of  the  incision  on  the 
front  of  the  leg.  A  similar  incision 
is  carried  round  the  inner  side  of  the 
leg,  and  thus  two  somewhat  quad- 
rilateral flaps  with  rounded  corners, 
consisting  only  of  skin  and  subcu- 
taneous tissue,  are  mapped  out.     The 

•J j^  lowest  point  of  the  flaps  is  about  1| 

inch  below  the  level  of  the  tubercle 
of  the  tibia.     They  are  dissected  up 

B    as   high   as    the    articulation.      The 

patella  is  removed,  and  the  various 
structures  around  the  joint  are  di- 
vided by  a  circular  sweep  of  the 
knife." 

Compared  with  Stephen  Smith's 
operation,  Mr.  Pick's  procedure  has 
the  disadvantage  of  bringing  the 
cicatrix  too  far  forward  on  to  tlie 
anterior  aspect  of  the  stump. 

2.  Disarticulation  by  Elliptical 
Incision  (Bauden's  Operation). — 
The  instriiments  required  and  the 
'position  of  the  patient  and  of  the 
surgeon  are  the  same  as  in  the 
previous  operation. 

The   inter-articular   line    having 
been  made  out,  the  antero-posterior 
diameter   of  the   limb   at  this  line  is  estimated.     The  ellip- 
tical incision  is  so  planned  that  its  lowest  part  crosses  the 
crest  of  the  tibia,  at  a  distance  below  the  joint-line  equal  to 


Fig.  143.  — A,  Disarticulation  at 
the  knee  by  the  elliptical 
method  (Bauden's  operation)  ; 
B,  Henry  Lee's  amputation  of 
the  leg. 


AMPUTATION  AT   THE  KNEE-JOINT.  497 

the  antero-posterior  diameter  of  the  limb.  The  highest  part 
of  the  ellipse  reaches  the  median  line  posteriorly  at  a  distance 
of  half  a  diameter  below  the  same  line.  The  incision  is 
inclined  at  an  angle  of  about  30  degrees  (Fig.  143,  a). 

The  incision  is  carried  through  the  integuments,  which 
are  then  well  freed  along  the  whole  extent  of  the  wound. 

The  skin  on  the  anterior  aspect  of  the  Hmb  is  turned  up  in 
the  form  of  a  cuff,  while  that  upon  the  posterior  side  of  the 
leg  is  displaced  upwards  by  gliding  merely. 

13y  the  employment  of  these  two  methods  the  integuments 
are  retracted  as  far  as  the  patella,  the  knee-joint  being  kept 
extended  during  the  process. 

The  limb  is  now  flexed  a  little,  the  patellar  Hgament  is 
divided,  and  the  articulation  is  entered  by  passing  the  knife 
between  the  semilunar  cartilages  and  the  head  of  the  tibia, 
as  in  the  operation  last  described. 

Both  the  patella  and  the  semilunar  cartilages  are  pre- 
served. 

The  ligaments  having  been  divided  as  already  described, 
the  soft  parts  at  the  back  of  the  joint  are  severed  by  a 
circular  cut  with  the  knife,  made  from  before  backwards. 
(See  page  459.) 

The  cicatrix  resulting  from  this  operation  is  transverse, 
and  is  placed  "upon  the  posterior  aspect  of  the  hmb.  A  very 
excellent  stump  is  obtained. 

3.  Disarticulation  by  Long  Anterior  Flap. — This  is 
sometimes  known  as  Pollock's  operation,  the  procedure 
having  been  elaborated  by  that  surgeon. 

Both  of  the  flaps  are  skin-flaps,  and  are  somewhat  rect- 
angular in  outline  (Fig.  140,  b). 

The  following  is  Mr.  Pollock's  description  (Medico- 
Chirurgical  Transactions,  vol.  liii.,  1870) : — "  I  feel  for  the 
interval  between  the  edges  of  the  outer  condyle  and  head  of 
the  tibia,  and  commence  my  incision  at  that  point,  and  im- 
mediately behind  the  edge  of  the  hamstring  muscle  as  it 
crosses  that  space.  I  take  especial  care  never  to  commence 
my  incision  higher  than  the  margin  of  the  condyle.  The 
incision  should  be  carried  perpendicularly  doTsmwards  on  the 
side  of  the  leg  till  nearly  five  inches  below  the  lower  edge  of 
the  patella,  then  gradually  brought  across  the  front  of  the  leg, 


498  OPERATIVE    SURGERY. 

and  when  crossing  the  tibia  should  be  quite  five  inches  below 
the  patella,  then  carried  up  the  inner  side  to  a  point  correspond- 
ing exactly  to  that  from  which  the  incision  commenced.  I 
usually  make  the  posterior  flap  by  cutting  from  without 
inwards ;  it  should  not  be  too  short,  and  should  consist  merely 
of  integument.  As  soon  as  the  flaps  are  completed,  all  the 
structures  round  the  joint  should  be  divided  at  right  angles 
with  the  limb."     The  patella  is  left. 

The  resulting  cicatrix  is  transverse,  and  is  placed  upon 
the  posterior  aspect  of  the  stump. 

Comment. — Other  methods  of  di?  ariculating  at  the  knee- 
joint  may  be  mentioned,  such  as  the  operation  by  equal 
anterior  and  posterior  flaps,  and  the  operation  by  cutting  a 
single  long  posterior  flap  from  the  soft  parts  of  the  cah'.  The 
three  most  noteworthy  methods,  however,  are  those  just 
given. 

Of  these  the  best  is  certainly  that  first  described — the 
disarticulation  by  lateral  flaps.  This  operation  is  simple  and 
is  easily  performed;  it  makes  no  great  demands  upon  the 
tissues  on  any  one  side  of  the  Hmb ;  it  leaves  a  wound 
well  adapted  for  satisfactory  drainage,  and  an  admhable  stump 
with  a  well-protected  cicatrix.  The  flaps,  moreover,  are  well 
nourished. 

Most  of  these  advantages  can  be  claimed  for  the  second 
operation — that  by  the  elliptical  incision.  In  this  proce- 
dure no  great  demands  are  made  upon  the  soft  parts  of  the 
leg,  and  the  wound  admits  of  satisfactory  drainage.  The 
operation,  however,  is  not  so  easy  to  perform  ;  the  cicatrix  is 
transverse,  and  is  consequently  not  so  well  protected  as  it 
is  in  Stephen  Smith's  operation,  where  it  sinks  into  the  inter- 
condyloid  notch.  By  both  these  operations  an  excellent  cover- 
ing is  provided  for  the  condyles. 

The  operation  by  the  long  anterior  flap  was  for  many 
years  the  chief  method  employed  by  English  surgeons  for 
amputations  at  the  knee-joint.  The  method,  however,  does 
not  compare  favourably  with  the  two  operations  already 
alluded  to.  The  long  anterior  flap  does  not  in  the  first  place 
provide  so  good  a  covering  for  the  condyles.  In  the  second 
instance  it  is  of  so  great  a  length,  and  so  thin  in  substance, 
that   it  is   of  necessity   ill-nourished    and   liable    to  slough. 


AMPUTATION  AT  THE  KNEE-JOINT.  499 

This  circumstance  offers  the  most  serious  objection  to  the 
operation.  In  84  examples  of  disarticulation  by  the  long 
anterior  flap,  tabulated  by  Bryant  and  Pick,  sloughing  followed 
in  no  less  than  19  cases — i.e.,  in  55  per  cent.  In  some  of  the 
instances  the  sloughing  Avas  very  extensive. 

In  twenty-one  of  Mr.  Bryant's  cases  in  which  Stephen 
Smith's  operation  was  performed,  sloughing  of  the  flaps  oc- 
curred in  only  four  instances,  and  in  all  of  these  the  process 
was  of  a  limited  extent. 

It  would  appear  also  that  in  the  procedure  by  elliptical 
incision,  sloughing  is  equally  or  even  less  uncommon. 

The  operation  by  the  long  anterior  flap  makes,  moreover,  a 
great  demand  upon  one  particular  side  of  the  limb,  the  wound 
is  not  so  well  adapted  for  spontaneous  drainage,  and  in  the 
resulting  stump  the  cicatrix  is  not  quite  so  favourably 
placed. 

The  long  posterior  flap  has  nothing  to  recommend  it.  The 
flap  made  is  heavy  and  cumbrous  ;  it  is  very  apt  to  slough 
and  to  undergo  considerable  retraction. 

The  operation  may  be  entertained  in  cases  of  localised 
destruction  of  the  integuments  of  the  front  of  the  leg. 

4FTER-TEEATMENT   OF   AMPUTATIONS   AT   THE    KNEE-JOINT. 

The  stump  should  not  be  covered  up  by  the  bed-clothes 
(page  69).  The  limb  should  be  slightly  raised  upon  a  firm 
piUow.  To  this  support  the  thigh  should  be  hghtly  secured — 
in  such  a  way  that  the  extremity  of  the  stump  projects  a  httle 
beyond  the  end  of  the  pillow  or  cushion. 

In  none  of  the  operations  named  is  a  splint  requu'ed. 

Excellent  drainage  is  offered  by  the  position  of  the  wound, 
and  drainage-tubes  should  only  be  used  in  exceptional  cases. 
In  no  circumstances  should  a  tube  be  passed  right  across 
the  wound  from  one  end  to  the  other.  There  is  often  con- 
siderable strain  upon  the  sutures,  which  should  not  be  removed 
too  soon.  Silkworm-gut  sutures  may  be  left  in  for  ten,  or 
even  fourteen,  days  if  necessary. 


o  6  2 


500 


CHAPTER    XXX. 

Amputation  of  the  Thigh  through  the  Condyles. 

In  this  operation  the  femur  is  divided  at  the  bases  of  the 
condyles,  about  the  level  of  the  tubercle  for  the  insertion  of 
the  adductor  magnus  tendon,  or  a  little  above  that  spot.  The 
patella  is  removed. 

Anatomical  Points. — The  femur  at  the  level  named  is  still 
of  considerable  width,  and  is  comj)osed  of  cancellous  tissue. 
The  medullary  canal  does  not  commence  until  the  narrower 
part  of  the  shaft  of  the  bone  is  reached,  some  inches  above 
the  inter-articular  line. 

The  trochlear  surface  of  the  femur  reaches  much  higher 
up  on  the  external  than  on  the  internal  condyle.  The  former 
process  is  somewhat  more  prominent  anteriorly. 

A  horizontal  saw-cut  made  at  the  level  of  the  adductor 
magnus  tubercle  will  remove  the  whole  of  the  bone  carrying 
articular  cartilage.  Such  a  cut,  indeed,  just  touches  the  upper 
limit  of  the  cartilage.  This  saw-line  also  corresponds  to  the 
epiphyseal  line. 

The  lower  epiphysis  does  not  join  the  shaft  until  the  age 
•>f  20  years.  In  young  subjects  the  saw  should  be  passed,  if 
possible,  below  the  epiphyseal  line. 

The  only  muscular  fibres  attached  about  the  bases  of  the 
condyles  belong  to  the  gastrocnemius  and  plantaris  muscles, 
and  to  the  lower  part  possibly  of  the  adductor  magnus. 

At  the  level  of  the  saw-line  the  graciUs  and  semi- 
tendinosus  are  wholly  tendinous  ;  the  sartorius  is  still 
muscular,  and  the  biceps  and  semi-membranosus  are  still  in 
great  part  muscular.  The  pophteus  arises  below  the  level  of 
the  saw-line. 

The  patella  is  removed  in  the  operation,  and  as  the 
important  fibrous  expansions  on  either  side  of  it,  belonging  to 


AMPUTATION  THROUGH  FEMORAL   CONDYLES.      501 

the  vasti,  are  divided,  tlie  quadriceps  is  set  free,  and  consider- 
able retraction  of  the  fibres  of  that  muscular  mass  must  be 
anticipated. 

The  synovial  pouch,  extending  upwards  between  the 
quadriceps  and  the  femur,  has  been  alluded  to  (page  492). 

At  the  level  of  the  saw-line  the  popliteal  artery  is  resting 
obliquely  against  the  inner  segment  of  the  bone.  The  vein 
lies  behind  it  and  to  its  outer  side.  The  nerve  is  quite  to  its 
outer  side. 

Instruments. — Amputating-knife  five  to  six  inches  in 
length  as  regards  its  blade.  Stout  scalpel.  Butch  fir's  saw. 
Retractors.  Six  pressure  forceps.  Artery  and  dissecting 
forceps ;  scissors,  etc.     Lion  forceps  may  be  required. 

Position. — The  position  of  the  surgeon  and  of  his 
assistants  is  the  same  as  in  the  last  series  of  operations 
(page  493). 

Three  methods  will  be  described  : — 

1.  Garden's  operation. 

2.  Modification  of  Garden's  operation. 

3.  Gritti's  operation. 

1.  Garden's  Operation. — Mr.  Richard  Garden's  operation 
was  first  described  in  the  British  Medical  Journal  for  April, 
1864,  although  that  surgeon  had  carried  out  the  method  now 
known  by  his  name  since  1846. 

"  This  operation,"  he  writes,  "  consists  in  reflecting  a 
rounded  or  semi-oval  flap  of  skin  and  fat  from  the  front  of  the 
joint,  dividing  everything  else  straight  down  to  the  bone,  and 
sawing  the  bone  slightly  above  the  plane  of  the  muscles,  thus 
forming  a  flat-faced  stump  with  a  bonnet  of  integument  to  fall 
over  it.  .  .  .  The  operator,  standing  on  the  right  side  of  the 
leg,  seizes  it  between  the  left  forefinger  and  thumb,  at  the  spot 
selected  for  the  base  of  the  flap,  and  enters  the  point  of  the 
knife  close  to  his  finger,  bringing  it  round  through  skin  and 
fat  below  the  patella  to  the  spot  pressed  by  his  thumb  ;  then 
turning  the  edge  downwards  at  a  right  angle  with  the  line 
of  the  limb,  he  passes  it  through  to  the  spot  where  it  first 
entered,  cutting  outwards  through  everything  behind  the 
bone.  The  flap  is  then  reflected,  and  the  remainder  of  the 
soft  parts  divided  straight  down  to  the  bone  ;  the  muscles  are 
then  slightly  cleared  upwards,  and  the  saw  is  applied," 


502  OPERATIVE    SUBGEBY. 

The  procedure  might  be  described  in  greater  detail  as 
follows  : — 

1.  The  incision  is  commenced  at  the  most  prominent  part 
of  the  tuberosit}^  of  one  condyle,  and  ends  at  a  corresponding 
point  on  the  other  condyle.  The  cut  over  the  front  of  the 
limb  sweeps  with  an  easy  curve  between  these  two  points,  and 
crosses  the  median  line  about  the  middle  of  the  patellar  liga- 
ment.    The  posterior  incision  is  quite  horizontal  (Fig.  133,  c). 

The  anterior  cut  is  made  first.  The  points  of  starting  and 
ending  may  be  marked  by  the  thumb  and  forefinger,  as  Garden 
advises.  The  knee-joint  is  a  Httle  Hexed  as  this  incision  is 
being  made.  In  the  right  limb  it  is  commenced  on  the  inner 
side,  and  in  the  left  extremity  on  the  outer  side.  The  assistant 
rotates  the  Hmb  as  the  linife  passes  across  it. 

The  posterior  incision  is  made  by  one  single  transverse 
sweep.  Both  incisions  should  involve  at  first  only  the  skin  and 
the  subcutaneous  tissues. 

2.  The  limb  being  extended,  the  anterior  flap  is  dissected 
up,  containing  all  the  soft  parts  down  to  the  patella  and  the 
capsule  of  the  joint.  The  posterior  "  flap "  may  be  a  little 
freed  and  allowed  to  ghde  up,  in  order  to  aid  the  separation  of 
the  anterior  flap. 

3.  The  knee  being  flexed,  the  joint  is  opened  by  cutting 
through  the  quadriceps  tendon  just  above  the  patella.  That 
bone  is  seized  by  the  surgeon,  and  the  anterior  capsule  divided 
on  either  side.  The  crucial  and  lateral  ligaments  are  cut. 
With  one  vigorous  sweep  of  the  knife  the  tissues  at  the 
posterior  aspect  of  the  limb  are  then  divided  down  to  the 
bone  at  the  level  of  the  hinder  skin  incision. 

A  few  touches  with  the  knife  serve  to  entirely  separate  the 
leg. 

4.  The  soft  parts  are  now  retracted  so  as  to  clear  the  bone 
for  the  passage  of  the  saw.  In  dividing  the  femur  the  saw 
must  be  kept  parallel  to  the  articular  surface  and  perj^en- 
dicular  to  the  shaft. 

In  young  subjects  regard  must  be  had  for  the  epiphyseal 
line. 

Hcemorrhage. — The  popliteal  artery  is  divided  close  to 
the  bone  at  its  inner  aspect.  Some  muscular  branches  may 
require  ligature. 


AMPUTATION   THROUGH  FEMORAL   CONDYLES.      503 

On  the  cut  surface  of  the  posterior  flap  will  be  found  the 
two  superior  articular  branches  from  the  popliteal  (divided 
close  to  the  femur),  and  the  anastomotica  magna  (on  the  inner 
side).  Branches  of  the  latter  vessel  and  of  the  descending 
portion  of  the  external  circumflex  may  require  to  be  secured 
in  the  margins  of  the  anterior  Hap. 

Comment. — "  When  the  soft  parts  are  thickened  and  con- 
densed by  inflammation,  the  integuments  cannot  well  be 
reflected  above  the  patella  with  such  incisions  of  the  skin. 
But  the  difliculty  may  be  got  over  by  cutting  into  the  joint  as 
soon  as  the  hgamentum  patellae  is  exposed,  and  at  once 
removing  the  leg  by  dividing  the  ligaments  and  hamstrings ; 
after  which  the  soft  parts  can  be  retracted  from  the  femur 
sufficiently  to  permit  the  application  of  the  saw.  The  arteries 
having  then  been  secured,  t-ie  patella  is  dissected  out  at 
leisure  "  (Lister). 

2.  Modifications  of  Garden's  Operation. — a.  Sir  Joseph 
Lister  ("  Holmes'  System  of  Surgery,"  vol.  iii.,  1883)  writes 
as  follows  : — 

"  I  found  it  advantageous  to  form  a  short  posterior  skin 
flap,  both  for  the  sake  of  co-aptation  of  the  cutaneous  margins 
without  j)uckering,  and  as  a  useful  addition  to  the  covering 
for  the  end  of  the  stump. 

"  The  surgeon  flrst  cuts  transversely  across  the  front  of  the 
limb,  from  side  to  side,  at  the  level  of  the  anterior  tuberosity 
of  the  tibia,  and  joins  the  horns  of  this  incision  posteriorly  by 
carrying  the  knife  at  an  angle  of  forty-five  degrees  to  the  axis 
of  the  leg  through  the  skin  and  fat  (Fig.  133,  d).  The  limb 
being  elevated,  he  dissects  up  the  posterior  skin-flap,  and  then 
proceeds  to  raise  the  ring  of  integument  as  in  a  circular  opera- 
tion, taking  due  care  to  avoid  scoring  the  subcutaneous  tissue, 
and  dividing  the  hamstrings  as  soon  as  they  are  exposed ;  and 
bending  the  knee,  he  finds  no  difliculty  in  exposing  the  upper 
border  of  the  patella.  He  then  sinks  his  knife  through  the 
insertion  of  the  quadricej)S  extensor,  and  having  cleared  the 
bone  immediately  above  the  articular  cartilage,  and  holding 
the  hmb  horizontal,  he  applies  the  saw  vertically,  and  at  the 
same  time  trans versel}',  to  the  axis  of  the  hmb  (not  of  the 
bone),  so  as  to  ensure  a  horizontal  surface  for  the  patient  to 
rest  on." 


504 


OPERATIVE    SURGERY. 


B.  Farabeufs  modification  of  Garden's  procedure  is  prac- 
tically a  new  operation.  The  femur  is  divided  at  the  same 
level,  but  different  flaps  are  cut.  The  anterior  flap  exceeds 
in  length  the  antero-posterior  diameter  of  the  limb  at  the 
saw-line  by  about  an  inch.  The  posterior  flap  is  equal 
to  half  that  diameter.  The  lateral  incisions  which  mark 
out  the  anterior  flap  commence  just  below  the  joint-line 
(Fig.  144).  The  outer  cut  descends  on  the  fibula,  the  inner  is 
placed  about  two  inches  behind  the 
inner  edge  of  the  tibia.  The  anterior 
flap,  therefore,  will  occupy  more  than 
half  the  circumference  of  the  limb. 

The  steps  of  the  operation  are  pre- 
cisely the  same  as  in  Garden's  method. 
An  excellent  stump  is  provided. 

The  cicatrix  in  all  these  operations 
is  found  upon  the  posterior  aspect  of 
the  limb. 

3.  Gritti's  Operation. — This  opera- 
tion, designed  by  Rocco  Gritti,  of  Milan, 
in  1857  (Annali  Universali  cli  Medi- 
cina,  Milan,  1857),  is  an  appHcation  of 
the  osteo-plastic  method  of  Pirogofi'  to 
amputations  at  the  knee. 

The  patella  is  retained,  but  its  ar- 
ticular surface  is  removed  with  the 
saw.  To  effect  this  the  bone  has  practically  to  be  bisected. 
The  femur  is  divided  transversely  at  the  upper  edge  of  the 
articular  surface — i.e.,  about  the  level  of  the  adductor  magnus 
tubercle. 

The  two  sawn  surfaces  of  bone  are  brought  together,  and  it 
is  presumed  that  they  will  unite,  that  the  patella  will  form 
the  summit  of  the  stump,  and  that  upon  it  the  weight  of  the 
body  will  be  borne. 

Operation. — The  position  ot  the  patient,  and  of  the  surgeon 
and  his  assistants,  is  the  same  as  in  the  preceding  operations. 
In  addition  to  the  instruments  enumerated,  the  following  are 
required  : — A  fine  metacarpal  saw,  or  small  Butcher's  saw, 
for  the  patella;  a  pair  of  lion  forceps  to  hold  the  patella; 
cutting  pliers,  in  the  event  of  the   articular   surface  of  the 


144. — 1'AKABh.UF'S  AM- 
PUTATld>f  THKOTJGH  THE 
CONDYLES  OF  THE  FEMUR. 

A,  Line  of  saw-cut. 


AMPUTATION  THROUGH  FEMORAL   CONDYLES.      505 

patella  being  removed  by  cutting  rather  than  by  the  saw; 
a  bone-drill ;  stout  catgut  or  wire  sutures  or  pegs  for  the  bones. 

An  anterior  flap  is  made  which  commences  on  either  side 
at  the  level  of  the  tuberosities  of  the  femoral  condyles,  and 
which  reaches  below  to  the  lowest  part  of  the  tubercle  of  the 
tibia.  This  flap  is  rectangular  in  outHne  (Fig.  131,  d).  The 
skin  at  the  back  of  the  limb  is  divided  transversely  or  by  an 
incision  which  is  inclined  a  little  downwards.  The  general 
steps  of  the  operation  are  the  same  as  those  already  given. 

The  anterior  flap  is  dissected  up  as  soon  as  the  ligamen- 
tum  patelloe  has  been  divided  at  its  insertion.  This  flap  is 
turned  up  with  the  patella  in  it  undisturbed.  The  knee- 
joint  having  been  opened,  disarticulation  is  effected,  and  the 
soft  parts  at  the  back  of  the  limb  are  divided  by  a  sweep  of 
the  knife.  The  lower  end  of  the  femur  is  removed  with  the 
saw.  Finally,  the  articular  surface  of  the  patella  is  sawn  off 
or  removed  by  cutting  pliers. 

The  parts  are  finally  adjusted  when  all  the  bleeding  points 
have  been  secured.     The  cicatrix  is  entirely  posterior. 

Gritti  appears  to  have  employed  no  especial  means  for 
keeping  the  two  bony  surfaces  in  close  contact. 

The  sawing  of  the  patella  presents  the  only  difficult  step 
in  the  operation.     The  bone  has— as  it  were — to  be  split. 

The  patella  should  be  held  vertically  by  an  assistant, 
who  grasps  the  anterior  flap  with  both  hands,  and  so  holds 
it  that  the  bone  is  made  to  stand  out  from  its  surface. 
Another  assistant  should  steady  the  bone  with  a  pair  of 
broad  lion  forceps  while  the  saw  is  being  entered. 

During  the  process  of  sawing,  the  surgeon  should  grasp 
the  ligamentum  patellae  with  stout  forceps,  held  in  the  left 
hand.  In  order  to  take  advantage  of  this  means  of  steadying 
the  patella,  the  ligament  should  be  cut  as  long  as  possible. 

There  appears  to  be  no  advantage  to  be  gained  by 
removing  the  cartilage  with  cutting  pliers. 

Sir  W.  Stokes  has  considerably  modified  this  operation. 
He  points  out  that  there  is  always  a  difficulty  in  keeping 
the  two  bony  surfaces  together.  These  surfaces  differ  very 
materially  in  size,  and  the  fragment  of  the  patella  is  very 
apt  to  sHde  to  and  fro  upon  the  wide  surface  of  the  divided 
condyles. 


506  OPERATIVE    SURGERY. 

Moreover,  so  low  down  is  the  femur  sawn  that  it  is 
sometimes  difficuh  to  bring  the  patella  in  easy  contact  with 
it.  The  fragment  of  the  knee-cap  may  have  to  be  forced 
into  position.  The  strain  thus  placed  upon  the  quadriceps  is 
soon  removed  by  the  contraction  of  that  muscle,  and  the 
patella  is  drawn  forwards  and  made  to  assume  an  oblique 
position.  It  then  becomes  a  veritable  foreign  body  in  the 
stump,  and  has  led  to  caries  of  the  bones  and  to  a  tender  and 
painful  extremity.  To  overcome  these  objections  Stokes 
divides  the  femur  higher  up — viz.,  at  a  point  from  half  to 
three-quarters  of  an  inch  above  the  condyles.  The  section 
of  the  bone  at  this  level  is  more  nearly  equal  in  size  to  that 
of  the  divided  patella.  At  the  same  time  it  is  not  suffi- 
ciently high  up  to  expose  the  medullary  canal. 

Different  flaps  are  cut.  The  anterior  flap  is  oval,  and 
reaches  from  a  point  one  inch  above  either  condyle  to  a 
point  just  below  the  tubercle  of  the  tibia.  A  posterior  flap 
is  formed,  which  is  at  least  one-third  of  the  length  of  the 
anterior  flap. 

The  bones  may  be  kept  in  position  either  by  closely 
suturing  the  soft  parts  above  the  patella  to  the  posterior 
flap,  or  by  drilling  the  bones  and  securing  them  by  wire  or 
catgut  sutures  or  by  pegs. 

A  distinction  between  Gritti's  operation  and  Stokes's 
modification  of  the  same  has  been  made  by  describing  the 
former  as  a  trans-condyloid  amputation,  and  the  latter  as  a 
supra-condyloid. 

Comment — In  commenting  upon  these  various  procedures 
it  may,  in  the  first  place,  be  said  that  the  best  method  of 
removing  the  Hmb  about  the  knee  is  undoubtedly  by  dis- 
articulation. The  advantages  of  this  procedure,  when  com- 
])ared  with  amputations  through  the  limb  immediately  above 
the  knee,  have  been  already  dealt  with  (page  490).  When 
comparing  the  operations  through  the  condyles  (just  described) 
with  amputations  through  the  shaft  of  the  femur,  considerable 
advantages  must  be  allowed  to  attend  the  former  procedures. 

In  the  first  place,  the  stump  loft  after  an  amputation 
through  the  femoral  shaft  will  not  bear  direct  pressure,  the 
weight  of  the  body  cannot  be  borne  upon  it,  and  the  artificial 
liml)  worn  must  take  its  main  support  from  the  pelvis. 


AMPUTATION  THROUGH  FEMORAL   CONDYLES.      507 

In  the  amiDiitations  through  the  condyles,  a  broad  section 
of  bone  is  left  in  the  stump,  and  the  skin  covering  the 
extremity  is  accustomed  to  bear  pressure  (as  in  kneeling). 
It  follows  that  the  stumps  left  after  such  operations  can  bear 
direct  pressure,  and  the  importance  of  this  fact  cannot  weU 
be  exaggerated. 

The  other  advantages  to  be  claimed  for  these  condylar 
operations,  when  compared  with  amputations  through  the 
shaft,  are  these: — The  limb  is  removed  lower  down,  there 
is  less  shock,  and  the  medullary  canal  is  not  opened  up. 
Muscular  attachments  are  but  Uttle  disturbed,  and  such 
muscles  as  are  divided  are  cut  in  their  tendinous  parts,  and 
not  where  the  tissues  are  thick  and  vascular.  The  function  of 
the  adductors  is  scarcely  at  all  disturbed.  There  is  little 
muscular  retraction,  and  but  shght  disposition  for  the  end  of 
the  bone  to  protrude,  or  for  a  conical  stump  to  result.  Both 
these  comphcations  are  not  uncommon  after  amputations 
through  the  lower  part  of  the  thigh. 

Of  the  methods  described,  Garden's  operation  is  probably 
the  best.  If,  however,  the  flaps  are  cut  precisely  as  Garden 
directed,  they  will  often  be  found  to  provide  but  a  scanty 
covering  for  the  bones.  This  operation,  when  performed 
upon  the  cadaver,  appears  to  be  in  every  respect  admirable, 
but  it  is  a  Httle  less  satisfactory  on  the  hving.  A  flap  cut 
from  the  front  of  the  knee  in  the  Hving  subject  will  retract 
one-third  of  its  length  after  it  has  been  separated  from  the 
deeper  parts.  Thus  a  flap  six  inches  in  length  will  shorten 
to  one  of  four  inches. 

Either  of  the  two  modifications  of  Garden's  operation  is 
to  be  recommended  in  the  place  of  the  original  procedure. 
They  both  give  admirable  results. 

Considerable  differences  of  opinion  have  been  expressed 
as  to  the  value  of  Gritti's  operation.  There  is  no  evidence  to 
show  that  the  presence  of  the  patella  in  the  stump  adds  very 
greatly  to  its  usefulness,  nor  improves  its  capacity  for  bearing 
pressure.  Against  the  operation  as  described  by  Gritti,  the 
objections  already  detailed  in  the  description  of  the  procedure 
must  be  urged.  These  objections  are  met  by  Stokes's  modifi- 
cation of  the  method.  Excellent  results  have  been  obtained 
by  Stokes's  operation.     One  great  point  in  its  favour  depends 


508  OPERATIVE    SURGERY. 

upon  the  circumstance  that  the  soft  parts  in  the  anterior  flap 
are  but  httle  disturbed,  and  the  risks  of  sloughing  of  that  flap 
are  reduced  to  a  minimum. 

The  importance  of  retaining  the  attachment  of  the  quadri- 
ceps has  perhaps  been  a  Httle  exaggerated.  The  wasting  of 
that  muscle  after  Stokes's  operation  would  appear  to  be  as 
great  as  after  the  amputation  by  Garden's  method. 


6U9 


CHAPTER    XXXI. 

Amputation  of  the  Thigh. 

The  operations  so  named  concern  amputation  through  the 
shaft  of  the  femur,  and  occupy  an  intermediate  position 
between  disarticulation  at  the  hip-joint  on  the  one  hand, 
and  the  supra-condyloid  or  trans-condyloid  operations  on  the 
other.  For  the  most  part  they  involve  a  division  of  the  bone 
at  or  below  its  centre.  The  sub-trochanteric  amputation  is 
seldom  performed. 

These  operations  play  a  conspicuous  part  in  surgery,  being 
performed  for  many  injuries  and  diseases  of  the  leg,  and 
notably  also  for  affections  of  the  knee-joint  and  of  the  popU- 
teal  region. 

Practically,  every  known  form  of  amputation  has  been 
carried  out  m  this  part  of  the  Hmb,  and  nearly  every  method — 
excepting  that  by  a  large  posterior  flap — has  received  a  certain 
degree  of  support. 

The  procedures  themselves  are  involved  under  a  very 
exuberant  and  comphcated  nomenclature.  Operations  in  aU. 
essential  features  ahke,  have  been  separately  designed  by 
independent  surgeons,  and  where  the  names  of  the  authors 
have  been  retained  no  Httle  confusion  has  resulted. 

Recognised  methods  have  been  modified  in  so  many  ways 
that  a  classification  of  aU.  known  amputations  of  the  thigh 
becomes  exceedingly  involved. 

No  particular  advantage,  however,  would  appear  to  attend 
the  attempt  to  define  the  distinctive  features  of  such 
operations  as  those  of  Spence,  Sedillot,  Benjamin,  BeU,  and 
O'HaUoran,  or  to  retain  the  names  of  those  distinguished 
surgeons  in  association  with  specific  methods. 

Considerable  differences  of  opinion  exist  as  to  the  com- 
parative merits  of   the  various   amputations  in  this  region, 


510  OPERATIVE    SURGERY. 

and  many  of  the  statements  made  by  most  competent  men 
are  not  reconcilable. 

One  surgeon  (Stimson),  in  his  account  of  these  operations, 
makes  no  mention  of  the  circular  amputation,  and  states  that 
"  the  superiority  of  the  flap  operation  (in  this  part  of  the 
limb)  is  now  generally  admitted."  Another  writer  (Guerin), 
dealing  with  the  same  region,  observes,  "L'amputation  de  la 
cuisse  est  le  triomphe  de  la  methode  circulaire." 

In  the  account  which  follows,  it  has  only  been  possible  to 
make  a  selection  from  the  twenty  and  more  "  recognised 
methods." 

Anatomical  Points. — The  outline  of  the  diaphysis  of  the 
femur  is  well  known.  The  medullary  cavity,  as  a  distinct 
canal,  occupies  about  the  middle  two-fourths  of  the  shaft  of 
the  bone.  The  nutrient  canal  is  found  upon  the  linea  aspera, 
a  httle  way  above  the  centre  of  the  shaft.  The  vessel  it 
contains  is  directed  towards  the  hip. 

The  skin  of  the  thigh  is  somewhat  coarse  and  thick  upon 
the  outer  side  of  the  Hmb,  and  is  thinner  and  finer  on  the 
inner  aspect.  It  is  but  loosely  attached  to  the  parts  beneath, 
and  thus  it  follows  that  flaps  composed  of  the  integuments 
contract  considerably.  The  skin  is  a  little  more  firmly 
connected  with  the  deeper  parts  along  the  groove  between  the 
vastus  externus  and  the  hamstrings,  this  being  the  situation 
of  the  outer  inter-muscular  septum. 

The  whole  limb  is  invested  by  the  dense  fascia  lata,  which  is 

thinnest  on  the  inner  aspect  of  the  thigh,  and  thickest  exter- 

'  nally.     On  the  latter  surface  of  the  limb  is  the  ilio-tibial  band. 

In  muscular  subjects  the  outline  of  the  thigh  is  irregular 
on  section  ;  in  stout  and  non-nmscular  individuals,  and  in 
young  children,  it  is  more  or  less  evenly  rounded. 

The  great  mass  of  the  muscular  tissue  of  the  part  has 
some  attachment  to  the  femur.  Certain  muscles,  however — 
viz.,  the  hamstrings,  the  gracilis,  and  the  sartorius — are  free. 
Of  these  the  biceps  is  the  least  separate,  being  connected  with 
the  femur  below  the  centre  of  the  bone  by  means  of  its 
"  short  head."  It  happens,  therefore,  that  the  thigh  muscles 
retract  very  unequiilly  when  divided,  retraction  being  con- 
spicuous upon  the  posterior  and  internal  aspects  of  the  limb. 

In   a   section  (Braune)  through   the   thigh    at  its  upper 


AMPUTATION  OF  THIGH.  511 

third — jnst  below  the  lesser  trochanter— the  bone  is  found  to 
be  well  and  evenly  covered  with  muscles  in  front,  behind, 
and  on  the  inner  side.  It  comes  nearest  to  the  skin  at  the 
outer  aspect  of  the  thigh.  The  muscular  masses  are  extensive, 
and  a  considerable  portion  of  the  gluteus  maximus  comes  into 
the  section. 

When  the  limb  is  divided  transversely  through  the  middle 
of  the  femur,  it  will  be  found  that  the  bone  is  evenly 
surrounded,  and  is  about  the  centre  of  the  section.  The 
main  muscular  masses  are  formed  by  the  vasti,  the  crureus 
and  the  adductor  magnus.  The  section  of  the  last-named 
muscle  is  nearly  equal  in  extent  to  that  of  the  three 
hamstrings  taken  together  at  this  level.  The  biceps  and 
semi-tendinosus  are  here  quite  separate.  The  short  head  of 
the  biceps  is  commencing.  The  adductor  longus  is  small,  and 
the  adductor  brevis  has  disappeared.  The  linea  aspera  is 
most  prominent  at  this  part  of  the  shaft. 

A  transverse  section  at  the  lower  third — about  a  hand's- 
breadth  above  the  knee — shows  that  the  bone  is  now  nearest 
to  the  skin  on  the  anterior  aspect  of  the  hmb.  The  great 
bulk  of  the  muscle  tissue  is  behind  the  bone.  The  adductor 
longus  has  disappeared;  the  quadriceps  is  very  much  reduced; 
the  biceps  and  semi-membranosus  still  present  large  surfaces 
on  section  ;  the  semi-tendinosus  is  small ;  the  adductor  magnus 
is  considerably  reduced,  and  is  becoming  entirely  free  of  the 
femur. 

The  femoral  artery  ceases  at  the  commencement  of  the 
lower  fourth  of  the  thigh.  In  antero-posterior  flaps  the  vessel 
comes  in  the  anterior  flap  when  above  the  centre  of  the  hmb, 
and  in  the  posterior  when  below  that  point. 

At  the  apex  of  Scarpa's  triangle  the  femoral  vein  hes 
behind  the  artery  ;  below  that  spot  it  is  found  somewhat 
on  the  outer  side  of  that  trunk. 

The  internal  saphenous  nerve  accompanies  the  artery,  lying 
upon  its  anterior  surface.  Care  must  be  taken  that  it  is  not 
included  in  the  ligature  when  the  artery  is  secured. 

The  profunda  artery  terminates  at  the  commencement  of 
the  lower  third  of  the  thigh.  The  femoral  and  profunda 
veins  and  the  adductor  longus  are  interposed  between  it  and 
the  femoral  trunk. 


512 


OPERATIVE    SURGERY. 


The  anastomotica  magna  arises  from  tlie  femoral  just  before 
It  terminates.  The  superficial  branch  of  the  vessel  is  accom- 
panied to  the  inner  side 
of  the  knee  by  the  long 
saphenous  nerve. 

The  descending  branch 
of  the  external  circumflex 
artery  reaches  to  the  outer 
side  of  the  knee. 

The  following  methods 
of  amputating  the  thigh 
will  be  described : — 

1.  Circular  method. 

2.  Syme's  modification 
of  the  circular  method. 

3.  By  long  anterior  and 
short  posterior  flaps. 

4.  Teale's  operation. 

5.  By  equal  antero- 
posterior flaps. 

6.  By  lateral  flaps. 
The  comparative  value 

of  these  different  methods, 
and  their  applicabihty  to 
different  portions  of  the 
thigh,  are  considered  on 
page  522. 

Instruments 
amputating-knives.  (For 
the  circular  operation  the 
blade  should  be  about  7 
or  8  inches  in  length,  and 
for  cutting  flaps  by  trans- 
fixion about  9  to  10 
inches.  These  measure- 
ments refer  to  the  amputation  as  ap])licd  to  the  averaore 
adult  limb.  In  marking  out  skin-flaps,  and  in 
ing  up  the  integuments  in  the  circular  operation, 
knife  with  a  broad   blade  4  inches   in   length  and 


Large 


Fip.  14f>. — A,  Circular  amputation  of  thigh:  (a) 
Saw-line  of  8ame  ;  13,  Amputation  of  thigh  by 
equal  antero-iiosterior  flaps  :  (b)  Saw-line  of 
SHnie  ;  C,  Disarticulation  at  the  hip  by  ex- 
ternal racket  incision. 


dissect- 
a  stout 
a   well- 


rounded  point  should  be  used.     No  attempt  should  be  made 


AMPUTATION  OF   THIGH.  513 

to  complete  the  circular  amputation  with  one  long  knife.  In 
shaping  muscular  flaps  by  cutting — as  distinguished  from 
transfixion — the  stout  knife  with  a  four-inch  blade  should 
be  employed.  The  same  knife  may  be  conveniently  used  to 
clear  the  bone  for  the  saw — e.g.,  after  transfixion  flaps  have 
been  cut.)  A  full-si/cd  amputation-saw.  A  small  Butcher's 
saw,  to  shajDe  the  end  of  the  divided  femur.  A  dozen  pressure 
forceps.  Artery  and  dissecting  forceps.  Ketractors,  scissors, 
needles,  etc. 

Position. — The  patient's  buttocks  rest  upon  the  end  of 
the  table.  The  sound  leg  is  secured  out  of  the  way.  Means 
should  be  taken  to  prevent  the  body  from  slipping  off 
the  table.  The  surgeon  stands  to  the  right  of  the  limb 
in  the  case  of  either  extremity.  (He  will  always  be  able 
to  place  himself  to  the  outer  side  of  the  right  limb ;  but 
if  there  should  be  any  obstacle  in  the  way  of  his  standing 
to  the  inner  side  of  the  left  thigh,  it  will  be  found  that  he 
can  operate  from  the  outer  side  without  greatly  increased 
ditficulty.) 

One  assistant  sits  beyond  the  end  of  the  table,  to  hold 
and  manipulate  the  limb.  A  second  assistant  stands  to  the 
surgeon's  left  (or  to  his  right  if  the  operator  be  placed  to  the 
outer  side  of  the  left  limb) ;  his  duties  are  to  retract  the  skin 
(in  the  circular  ojDeration),  to  grasp  the  flaps  when  cut,  to  appl}^ 
the  retractors,  and  to  hold  the  stump  up  while  the  arteries 
are  being  secured.  The  third  assistant  stands  below  the 
surgeon  and  attends  to  the  sponging  and  the  securing  of  the 
bleeding  points. 

1.  The  Circular  Amputation. — Owing  to  the  unequal 
manner  in  which  the  divided  muscles  retract,  the  simple 
circular  operation  is  not  adapted  for  the  thigh.  In  order  to 
aUow  for  this  irregular  retraction,  the  incision  must  be  placed 
obhquely. 

This  operation  should  only  be  carried  out  in  the  lower 
third  of  the  limb.  Farabeuf  gives  the  following  directions 
for  the  incision : — 

On  the  anterior  and  outer  aspects  of  the  limb  the  distance 
between  the  level  of  the  proposed  saw-cut  and  the  incision  on 
the  skin  should  be  equal  to  one-fourth  of  the  circumference 
of  the  tliigh  at  the  former  point.     On  the  hinder  and  inner 

H    H 


514  OPERATIVE    SURGERY. 

aspects  of  tlie  limb  the  skin-incision  should  be  made  a  little 
less  than  half  this  length  lower  down  (Fig.  145,  a). 

For  example :  if  the  circumference  of  the  thigh  at  the 
proposed  saw-level  be  18  inches,  the  skin-incision  in  front  and 
on  the  outer  side  should  be  4|  inches  below  that  level,  while 
on  the  posterior  and  inner  aspects  of  the  limb  it  should  be 
6^  inches  below  the  same  point. 

Operation. — The  proposed  incision  should  be  marked  upon 
the  skin. 

1.  Standmg  to  the  outer  side  of  the  right  thigh,  the  surgeon 
passes  his  arm  beneath  the  limb,  and,  bringing  his  hand  as  far 
as  possible  over  the  front  of  the  thigh,  he  begins  the  incision 
in  the  skin  with  the  heel  of  the  knife,  at  a  spot  as  low  down 
upon  the  external  surface  as  can  be  reached.  The  assistant 
at  the  same  time  has  the  limb  rotated  forcibly  inwards. 
The  knife  is  now  made  to  pass  across  the  anterior,  internal  and 
posterior  surfaces  of  the  hmb  (in  order),  being  drawn  from 
the  heel  to  the  point.  The  assistant  rotates  the  thigh  in  an 
opposite  direction  as  the  knife  passes  round,  the  limb  being 
fully  rotated  outwards  when  the  incision  is  completed.  If  the 
skin-cut  be  not  made  at  one  sweep,  the  ends  of  the  wound 
should  be  joined  by  an  incision  from  above  downwards. 

The  surgeon,  standing  on  the  inner  side  of  the  left  thigh, 
follows  a  precisely  opposite  course,  the  incision  being  com- 
menced upon  the  inner  aspect  of  the  limb. 

2.  The  assistant  now  retracts  the  skin  while  the  surgeon 
frees  it  all  round.  It  must  be  retracted  evenly,  so  as  to  pre- 
serve the  original  obhquity  of  the  incision.  It  is  seldom 
possible  to  turn  back  a  culf  of  skin  as  some  advise.  In  a 
normal  adult  limb  such  a  course  is  mechanically  impractic- 
able. 

3.  When  the  skin  has  been  separated  from  the  deeper 
parts  and  retracted  as  far  as  required,  the  superficial  muscles 
on  the  inner  and  posterior  aspects  of  the  thigh  (the  ham- 
strings, sartorius  and  gracilis)  are  divided  by  a  vigorous 
sweep  of  the  knife.  When  they  have  retracted,  the  deeper 
nuiscles  are  severed  down  to  the  bone  at  the  highest  possible 
level  by  another  sweeping  cut. 

In  dividing  the  muscles  the  obliquity  of  the  original 
incision  is  still  maintained — i.e.    the  knife  crosses  the  hmb 


AMPUTATION  OF  THIGH.  515 

parallel  to  the  original  skin-cut,  and  as  close  as  possible  to  the 
now  retracted  margin  of  the  integument. 

4.  The  bone  is  cleared,  retractors  are  applied,  and  the 
femur  is  sawn  through.  "  In  sawing  the  femur  the  position 
of  the  thick  ridge  (linea  aspera)  at  its  posterior  aspect  is  to  be 
remembered,  and  the  saw,  at  first  horizontal,  must  be  brought 
nearly  vertical  so  soon  as  a  groove  is  cut,  in  order  that  the 
linea  aspera  may  be  divided  early,  and  not  left  to  break  and 
form  a  projecting  spike '"  (C.  Heath). 

It  is  well  to  saw  off  the  superior  and  inferior  margins  of 
the  end  of  the  bone  obliquely,  so  as  to  round  it.  This  may  be 
conveniently  performed  by  a  small  Butcher's  saw. 

The  cicatrix  will  be  transverse  or  oblique.  In  the  latter 
case  it  will  incline  from  in  front  backwards  and  inwards. 

Hcemorrhage. — The  position  of  the  femoral  artery  upon 
the  face  of  the  stump  wiU  depend  upon  the  level  at  which  the 
tissues  are  divided. 

If  the  amputation  be  through  the  lower  third  of  the  thigh, 
the  anastomotica  magna  will  be  divided.  If  above  this  level, 
the  profunda  will  be  found  to  be  cut.  The  descending  branch 
of  the  external  circumflex  artery  will  require  a  ligature  as  it 
hes  cut  on  the  antero-external  aspect  of  the  stump.  One  or 
more  of  the  perforating  arteries  and  many  muscular  branches 
may  need  to  be  secured. 

2.  Syme's  Modification  of  the  Circular  Amputation. — 
By  this  method  the  circular  operation  is  simphfied.  The 
skin  is  much  more  easily  dissected  up,  and  the  integuments 
are  less  roughly  handled  in  the  process  of  separation. 

The  operation  consists  practically  of  the  usual  circular 
incision,  with  two  lateral  cuts  to  aid  the  retraction  of  the  skin. 

Two  very  short  antero-posterior  flaps  of  semilunar  outline 
and  of  equal  width  and  length  are  dissected  up.  They  are 
composed  simply  of  the  integument  and  subcutaneous  tissues, 
and  consist  of  little  more  than  curved  incisions  made  across 
the  front  and  the  back  of  the  thigh,  each  being  equal  to  one- 
half  of  the  circumference  of  the  limb. 

The  skin  beyond  the  little  flaps  is,  in  its  turn,  separated — 
just  as  in  the  usual  circular  method — and  is  reflected  until  a 
point  is  reached  some  two  inches  above  the  bases  of  the  smaU 
antero-posterior  flaps. 

H   H   2 


516  OPERATIVE    SURGERY. 

The  anterior  femoral  muscles  are  now  divided  down  to  the 
bone  by  a  transverse  sweep  of  the  knife  at  the  level  of  the 
retracted  skin.  The  posterior  muscles  are  severed  in  like 
manner,  but  at  the  level  at  which  they  were  first  uncovered 
in  forming  the  posterior  flap. 

"  The  muscles,"  as  Syme  puts  it,  "  should  be  divided  right 
down  to  the  bone,  on  a  level  as  high  as  they  are  exposed  in 
front,  as  low  as  they  are  exposed  behind." 

The  muscular  tissue  after  division  is  further  retracted,  so 
as  to  clear  the  bone  well.  The  femur  is  ultimately  sawn  about 
two  inches  above  the  level  of  the  spot  at  which  the  anterior 
muscles  were  divided. 

3.  Amputation  by  Long  Anterior  and  Short  Posterior 
Flaps. — The  following  is  the  description  of  this  operation  as 
given  by  Farabeuf  His  method  is  a  shght  modification  of 
that  associated  with  Spence's  name.  An  excellent  covering 
for  the  bone  is  provided. 

The  position  of  the  surgeon  and  his  assistants  and  the 
instruments  used  have  been  already  detailed. 

It  is  assumed  that  the  femur  is  to  be  divided  about  its 
centre.  The  two  flaps  are  U-shaped.  The  anterior  flap  is 
equal  in  length  to  one  diameter  and  a  half  of  the  limb  at  the 
saw-line.  The  posterior  flap  has  the  length  of  one-half  the 
diameter  of  the  extremit}''  at  the  same  level.  The  anterior 
flap  is  the  wider,  its  base  exceeding  a  little  half  the  circum- 
ference of  the  hmb  (Fig.  146,  a). 

Operation. — 1.  The  limb  is  rotated  outwards  on  the  riglit 
side,  and  inwards  on  the  left.  The  anterior  flap  is  marked  out 
first.  In  the  right  thigh  the  surgeon  commences  with  the  inner 
limb  of  the  flap,  cutting  downwards.  He  then  carries  the  knife 
across  the  front  of  the  extremity,  and  finishes  with  the  outer 
limb  of  the  flap,  the  leg  being  now  rotated  inwards.  In  dealing 
with  the  left  limb  the  conditions  are  reversed,  and  the  cut  is 
first  made  upon  the  external  aspect.  The  incision  includes  the 
integuments  only. 

In  marking  out  the  posterior  flap  the  surgeon's  hand  is 
beneath  the  thigh,  and  the  knife,  being  entered  at  the  further 
limb  of  the  anterior  flap,  is  drawn  across  the  posterior  surface 
and  towards  the  operator.  This  cut  also  involves  the  integu- 
ments only. 


AMPUTATION   OF   THIGH. 


517 


The  leg  is  again  suitably  rotated  as  the  knife  passes  along 
its  course. 

2.  The  tissues  of  the  anterior  flap  are  now  pinched  up  with 
the  left  hand,  and  the  muscles  contained  therein  are  divided 
obliquely  from  without  inwards 
— i.e.,  from  the  skin  to  the  bone. 
The  soft  parts  are  so  cut  that  the 
flap  is  thinnest  at  its  extremity 
and  thickest  at  its  base.  At 
the  latter  site  it  will  include  the 
whole  thickness  of  the  muscular 
mass  in  front  of  the  femur.  The 
tissues  are  divided  obliquely 
(the  edge  of  the  knife  being 
turned  toAvards  the  bone  at  the 
base  of  the  flap)  in  distinction 
to  the  transverse  division  of 
parts  which  obtains  in  the  cir- 
cular amputation. 

The  muscles  of  the  posterior 
flap  may  be  conveniently  cut 
by  transfixion.  They  may,  how- 
ever, be  divided  in  the  same 
way  as  are  those  of  the  anterior 
flap.  Transfixion  is  better 
suited  for  muscular  hmbs. 

The  muscles  are  divided 
well  down  to  the  bone  at  the 
bases  of  the  flaps.  The  femur 
is  bared  by  further  retraction  of 
the  soft  parts,  and  is  sawn  in 
the  manner  already  described 
(page  515). 

Spence  ("  Lectures  on  Sur- 
gery," 2nd  ed.,  vol.  ii.,  page  621,  1876)  made  the  anterior  flap 
equal  in  length  to  the  diameter  of  the  limb,  and  the  breadth 
of  its  base  equal  to  "  almost  two-thirds  of  the  circumference 
of  the  thigh." 

The  posterior  flap  was  cut  from  without  inwards,  and  was 
conmienced  some  two  inches  below  the  base  of  the  anterior 


Fig.  146. — A,  Amputation  of  the  thigh 
by  long  anterior  and  short  posterior 
flaps;  B,  Disarticulation  at  the  hip 
by  antero -posterior  flaps. 


518  OPERATIVE    SURGERY. 

flap.  To  this  an  additional  inch  of  skin  was  sometimes  added 
Spence  considered  this  operation  as  especially  apphcable  to 
the  lower  third  of  the  thigh,  and  the  extremity  of  the 
large  anterior  flap  was  allowed  to  reach  as  low  as  the  lower 
margin  of  the  patella. 

Sedillot  ("  Medecine  Operatoire,"  vol.  i.,  page  455,  1854) 
made  the  anterior  flap  equal  to  one  diameter  of  the  limb  at 
the  saw-line,  and  its  base  equivalent  to  "  fully  one-half  of  the 
circumference."  There  was  no  posterior  flap,  the  structures  at 
the  back  of  the  hmb,  from  the  skin  to  the  bone,  being  divided 
by  one  vigorous  transverse  cut. 

Sedillot's  operation,  Avhen  performed  upon  a  muscular 
hmb,  scarcely  provides  a  sufficient  covering  for  the  bone. 

Hcemorrhage. — The  position  of  the  femoral  artery,  with 
reference  to  antero-posterior  flaps  generally,  may  here  be 
alluded  to. 

In  an  amputation  by  antero-posterior  flaps  made  above  the 
middle  of  the  thigh,  the  femoral  artery,  together  with  the  pro- 
funda, will  be  found  in  the  anterior  flap.  In  a  hke  amputation 
performed  below  the  middle  of  the  limb  the  main  arter}^  Avill 
be  divided  in  the  posterior  flap.  In  this  position,  hoAvever, 
there  is  risk  of  splitting  the  artery  if  the  anterior  flap  much 
exceed  in  width  one-half  of  the  circumference  of  the  limb. 
This  is  avoided  by  placing  this  flap  a  little  towards  the  ex- 
ternal aspect  of  the  limb  instead  of  fashioning  it  in  the  median 
segment.  When  the  amputation  is  carried  out  in  the  middle 
of  the  thigh,  the  anterior  flap  should  be  antero-external.  This 
will  bring  the  artery  in  the  posterior  flap. 

The  descending  branch  of  the  external  circumflex  artery 
wiU  always  be  found  divided  in  the  anterior  flap,  together  with 
many  muscular  branches.  In  the  lower  third  of  the  limb  the 
anastomotica  magna  will  be  divided  about  the  inner  part  of 
the  hinder  flap. 

In  the  angle  between  the  flaps,  and  in  the  muscular  tissue 
close  to  the  bone,  branches  of  the  perforating  arteries  will  be 
found  cut. 

It  is  needless  to  say  that  the  muscular  arteries  in  the  thigh 
are  large  and  numerous,  and  that  the  great  veins  require  to  be 
occluded  by  ligature. 

4.  Teale's  Operation. — This   procedure   when  applied  to 


AMPUTATIOX  OF  THIGH.  519 

the  thigh,  is  carried  out  upon  precisely  the  same  bases  as 
have  been  ah-eady  given  (page  469).  The  anterior  flap  is 
equal  in  width  and  in  length  to  one-half  of  the  circumference 
of  the  limb  at  the  level  of  the  saw-line. 

The  posterior  flap  is  one-fourth  of  the  length  of  the 
anterior. 

Both  flaps  are  rectangular  and  are  composed  of  the  integu- 
ments only.  The  anterior  flap  can  be  carried  well  down  over 
the  patellar  region.  Care  must  be  taken  that  this  flap  does  not 
become  narrow  as  it  descends. 

5.  Amputation  by  Equal  Antero-Posterior  Flaps. — This 
may  be  taken  as  a  t3rpe  of  the  amputation  of  the  thigh  by 
transfixion.  The  surgeon  stands  to  the  right  side  of  the  limb 
in  the  case  of  both  the  right  and  the  left  thighs.  The  length 
of  the  amputating-knife  must  be  influenced  by  the  width  of 
the  limb. 

In  order  that  the  flaps  should  be  of  equal  length  after  they 
are  cut,  it  is  necessary  that  the  posterior  flap  should  be  made 
a  httle  the  longer.  This  is  to  allow  for  the  greater  retraction 
of  the  posterior  muscles. 

Both  flaps  are  U-shaped,  and  the  base  of  each  is  equal  to 
one-half  the  circumference  of  the  limb.  The  posterior  flap 
should  be  the  length  of  the  diameter  of  the  thigh  at  the  saw- 
line.  The  anterior  flap  -will  be  equal  to  about  three-fourths  of 
that  diameter  (Fig.  145,  b).  Fergusson's  rule  was  that  the 
hinder  flap  should  be  one  inch  longer  than  the  anterior  one. 
These  measurements  will  be  found  to  about  coincide  with  the 
advice  given  in  older  books — to  the  effect  that  in  the  adult  the 
flaps  should  be  from  4  to  4|  inches  in  length. 

The  operation  is  performed  in  the  usual  way  (page  297). 

"  Grasping  the  soft  parts,"  Avrites  Fergusson,  "  so  as  to 
bring  them  well  forward,  I  push  the  knife  across  from  the 
outside  and  form  a  flap  in  front ;  this  being  shghtly  elevated, 
I  again  carry  the  knife  in  the  dii-ection  which  it  first  took, 
but  behind  the  bone,  and  form  the  second  flap  from  the 
posterior  surface." 

It  is  important  that  the  anterior  flap  should  be  of  its  proper 
width.  In  performing  transfixion  carelessly,  this  flap  is  apt  to 
be  made  a  gi'eat  deal  narrower  and  thinner  than  the  posterior 
one.     Before  the  knife  is  introduced  the  exact  limits  of  the 


5:20  OPERATIVE    SURGE liY. 

base  of  the  anterior  flap  should  be  marked  out.  The  substance 
of  the  future  flap  is  grasped  between  the  fingers  and  thumb  of 
the  left  hand.  The  thumb  and  forefinger,  indeed,  mark  the 
base  of  the  flap. 

After  the  flaps  have  been  dissected  up,  the  muscular  tissue 
about  the  bone  is  divided  with  a  stout  scalpel.  The  flaps,  vnth 
the  severed  tissues  occupying  the  angle  between  them,  are 
evenly  retracted  until  the  femur  is  exposed  at  the  spot  at 
which  the  saw  is  to  be  applied. 

In  very  muscular  limbs  the  knife,  in  transfixing  the  part, 
may  be  kept  a  little  away  from  the  bone,  so  that  only  the  more 
superficial  muscles  are  divided.  This  especially  applies  to  the 
cutting  of  the  posterior  flap.  When  this  has  been  done,  the 
deeper  muscles  are  severed  by  transverse  cuts,  as  in  the 
circular  operation. 

Directions  for  sawing  the  bone  have  been  already  given. 

Some  of  the  objections  which  apply  to  the  flap  method  are 
overcome  by  cutting  the  flaps  from  without  inwards,  precisely 
after  the  manner  described  in  the  account  of  the  amputation 
by  the  long  anterior  flap  (page  517). 

Hcemorrhage. — This  point  has  been  already  considered 
(page  518). 

When  planning  the  flaps  attention  must  be  paid  to  the 
position  of  the  main  blood-vessels. 

6.  Amputation  by  Lateral  Flaps. — This  method  is  often 
known  as  Vermale's  operation. 

It  appears  to  have  been  at  one  time  extensively  practised. 
It  has  been  considered  to  be  especially  applicable  to  the  lower 
thu'd  of  the  limb. 

The  flaps  are  both  of  the  same  size,  and  include  all  the 
soft  parts  down  to  the  bone.  It  may  be  convenient  to  make 
the  inner  flap  a  little  wider  than  the  outer,  so  as  to  include  as 
much  of  the  artery  as  possible  in  the  inner  flap. 

Each  flap  should  be  equal  in  length  to  the  diameter  of  the 
Hmb  at  the  level  of  the  saw-cut,  and  should  be  U-shaped 
(Fig.  141,  B). 

Both  are  cut  by  transfixion,  the  knife  being  entered  a  little 
below  the  point  at  which  the  bone  is  to  be  divided. 

Operation. — The  following  is  Fergusson's  account  of  the 
operation : — 


AMPUTATION  OF   THIGH.  521 

"  The  surgeon,  standing  on  the  outside  of  the  limb,  should 
grasp  the  soft  parts  on  the  outer  side  of  the  thigh  between  his 
fingers  and  thumb,  and  having  drawn  them  as  it  were  from  the 
side  of  the  bone,  should  pass  the  knife  from  before  backwards — 
or, rather,  fi-om  above  downwards — and  then  cut  do Avn wards  and 
outwards  so  as  to  form  a  flap  of  the  size  indicated  (Fig.  141,  b). 
Next  the  knife  should  a  second  time  be  introduced  in  front, 
and  carried  backwards  in  a  line  with  its  original  course,  but 
on  the  opposite  side  of  the  bone,  when  by  cutting  again  down- 
wards and  towards  the  surface,  the  inner  flap  is  formed.  Both 
of  them  should  then  be  drawn  upwards  with  considerable  force 
by  the  hands  of  an  assistant,  and  an  incision  made  round  the 
bone,  fully  an  inch  higher  than  the  place  of  transfixion.  The 
saw  should  then  be  appUed  in  the  course  of  this  last  cut.  In 
transfixing,  the  point  of  the  knife  should  be  thrust  directly 
down  to  the  femur,  with  which  it  should  be  kept  in  close 
contact  as  it  is  carried  round  to  the  opposite  surface. 

"The  assistant  who  has  charge  of  the  flaps  should  not 
forcibly  elevate  the  one  first  made,  as  the  knife  is  thereby 
prevented  from  passing  readily  across  the  Umb  the  second 
time.  He  can  scarcely,  however,  be  too  energetic — after  the 
other  is  cut — in  drawing  both  upwards,  so  as  to  give  plenty  of 
room  for  working  the  saw  without  rubbing  against  the  soft 
parts. 

"  I  am  generally  in  the  habit  of  making  the  inner  flap  first 
instead  of  the  outer,  as  I  can  thereby  see  the  progress  of  the 
knife  much  more  clearly  during  the  second  thrust." 

In  this  operation,  when  performed  in  the  lower  third,  the 
main  artery  is  very  apt  to  be  split,  even  when  every  pre- 
caution is  taken. 

Goviment. — Owing  to  the  uneven  manner  in  which  the 
muscles  of  the  part  retract,  and  to  the  extent  of  that  retrac- 
tion, a  conical  stump  is  not  uncommon  after  any  amputation 
of  the  thigh. 

The  retraction  concerns  mainly  the  posterior  and  internal 
segments  of  the  limb,  and  it  will  be  observed  that  the  cicatrix 
is  apt  to  be  drawn  backwards  and  to  the  inner  side.  This  may 
be  well  seen  after  a  simple  circular  amputation. 

Conical  stumps  are  more  common  below  than  above  tho 
middle  of  the  limb. 


522  OPERATIVE    SURGERY. 

In  amputations  made  through  the  lower  third  of  the  thigh 
it  should  be  remembered  that  the  bone  comes  nearest  to  the 
anterior  surface. 

When  the  limb  is  divided  above  the  middle  of  the  thigh, 
the  femur  is  apt  to  project  anteriorly.  This  is  due  partly  to 
the  contraction  of  the  psoas  and  ihacus  muscles,  and  partly  to 
the  weight  and  retraction  of  the  posterior  muscles. 

With  regard  to  the  selection  of  methods  : — 

The  objections  which  have  been  urged  against  the  circular 
operation,  and  the  advantages  which  it  may  claim  (page  301}, 
apply  very  especially  to  amputations  in  this  region. 

The  usual  circular  method  cannot  be  advised,  nor  is  any 
form  of  the  amputation  suited  for  the  middle  or  higher  part 
of  the  limb. 

The  modified  circular  operation  described  (No.  1)  and 
Syme's  operation  (No.  2)  are  adapted  for  the  lower  third  of 
the  limb,  especially  in  cases  where  a  long  anterior  flap  cannot 
be  cut,  for  children,  and  for  the  limbs  of  enfeebled  and  wasted 
subjects.  The  fact  that  the  wound-surface  is  comparatively 
small,  that  the  section  of  the  muscles  is  reduced  to  a  minimum, 
and  that  the  main  vessels  are  cleanly  divided,  are  distinctly  in 
favour  of  this  method. 

There  is  Httle  to  recommend  Teale's  operation  (No.  4)  in 
this  section  of  the  limb.  It  is  adapted  only  for  the  lower 
third.  It  certainly  ensures  a  good  covering  for  the  bone  and  a 
clean  division  of  the  main  artery.  It  may  be  of  value  when 
the  parts  upon  the  posterior  aspect  of  the  limb  are  damaged. 
It  has,  however,  these  disadvantages  ;  the  anterior  flap  is  long 
and  thin,  and  apt  to  slough ;  in  any  case,  its  edges  at  least  are 
apt  to  become  gangrenous.  The  large  flap  is,  moreover,  ditii- 
cult  to  adjust  and  to  keep  in  place. 

The  amiiutation  by  a  long  anterior  and  a  short  posterior 
flap  (No.  3)  is  perhaps  the  best  adapted  for  the  thigh  and  all 
parts  of  it. 

In  the  lower  third  of  the  limb  it  is  certainly  an  excellent 
operation.  Where  the  tissues  upon  the  front  of  the  thigh  are 
limited,  it  may  be  replaced  by  the  method  by  two  equal 
antero-posterior  flaps  (No.  5),  the  flaps  being  cut  in  the  same 
manner — i.e.,  from  without  inwards. 

Amputation  by  transfixion  has  already  been  discussed  (page 


AMPUTATION  OF  THIGH.  523 

302),  and  the  advantages  and  disadvantages  presented  by  the 
operation  are  conspicuous!}^  evident  in  this  part  of  the  body. 

V'ermale's  operation  (No.  6)  was  at  one  time  extensively 
practised.  It  has,  however,  very  httle  to  recommend  it.  The 
stump  looks  well  when  the  operation  has  been  performed 
upon  the  cadaver,  but  in  the  living  subject  it  will  be  found 
that  the  end  of  the  femur  has  a  gTeat  tendency  to  project 
forward  between  the  flajjs.  The  bone,  indeed,  cannot  be  well 
covered.  It  is  difficult  to  cut  the  flaj^s  neatly  by  transtixion  ; 
they  are  apt  to  retract  unequally,  and  it  is  not  unusual  to 
find  that  the  great  vessels  have  been  split  or  divided  unduly 
high  up  in  fashioning  the  internal  flap. 

In  some  limited  injuries,  as,  for  example,  in  a  gunshot 
wound  involving  the  front  of  the  limb,  the  operation  may  be 
considered  of  service.  It  is,  however,  the  least  satisfactory  of 
the  methods  here  described. 

AFTER-TREATMEXT   OF   AMPUTATIONS   OF   THE   THIGH. 

The  stump  should  be  exposed  to  the  air — covered,  of 
course,  by  suitable  dressings  (page  69).  The  thigh  should  be 
raised  and  supported  upon  a  firm  pillow  or  cushion,  to  which 
it  should  be  lightly  secured.  The  hmb  should  be  placed  in 
the  abducted  position.  The  extremity  of  the  stump  should 
project  beyond  the  end  of  the  pillow.  It  will  be  thereby 
exempted  fifom  pressure,  and  drainage  will  not  be  interfered 
with.  A  supporting  sphnt  is  not  required  in  these  amputa- 
tions, although  it  may  sometimes  be  employed  with  ad- 
vantage after  the  circular  operation  and  in  amputations 
through  the  lower  part  of  the  limb. 

It  is  scarcely  to  be  expected  that  these  large  wounds  will 
heal  up  throughout  by  first  intention.  A  few  sutures  should 
be  omitted  at  the  most  dependent  angle  of  the  wound,  to  allow 
for  drainage — or,  better  still,  a  short  tube  may  be  inserted  at 
that  situation.  The  oozing  during  the  first  twenty-four  hours 
is  considerable. 

In  no  rase  should  a  large  drainage-tube  be  dra-wn  right 

CO  O 

through  the  depths  of  the  wound,  from  one  extremity  of  the 
incision  to  the  other. 

As  the  flaps  are  large  and  heavy,  the  sutures  should  not 
be  removed  too  soon.  After  their  removal  the  flaps  may 
need  to  be  supported  for  a  while  by  strapping. 


524 


CHAPTER    XXXII. 

Disarticulation  at  the  Hip-Joint. 

This  amputation,  tlae  most  serious  the  surgeon  can  be 
called  upon  to  perform,  was  for  many  years  after  its  intro- 
duction attended  by  so  terrible  a  mortality  as  to  be  con- 
sidered an  entirely  unjustifiable  operation. 

The  first  amputation  at  the  hip  appears  to  have  been 
performed  by  Mr.  Henry  Thompson,  surgeon  to  the  London 
Hospital,  some  time  before  1777.  Previous  to  this — viz.,  in 
1743 — Ravaton  had  elaborated  an  operation,  which,  however, 
his  surgical  colleagues  would  not  allow  him  to  perform.  His 
method  consisted  in  a  vertical  external  incision,  through 
which  the  bone  was  to  be  enucleated  subperiosteally,  and 
disarticulation  effected ;  the  operation  was  to  be  completed  by 
a  circular  section  of  the  soft  parts.  This  procedure  is  prac- 
tically identical  with  the  modern  operations  of  Esmarch, 
Lister,  Furneaux  Jordan,  and  others  (page  531). 

Kerr,  of  Northampton,  amputated  at  the  hip  in  1778, 
using  an  oval  incision,  the  queue  of  which  terminated  ex- 
ternally. Through  the  outer  part  of  the  wound  disarticula- 
tion was  effected,  the  soft  parts  upon  the  inner  side  of  the 
limb  being  divided  subsequently. 

The  first  amputation  at  the  hip  in  military  practice  is 
accredited  to  Baron  Larrey  in  1793.  In  all  these  early  cases 
the  patient  died. 

Earle,  writing  in  1808  ("  Potts'  Chirurgical  Works,"  vol.  iii., 
page  217),  speaks  of  the  operation  as  "  horrid,"  "  dreadful,"  and 
"  unjustifiable,"  and  adds  :  "  I  have  seen  it  done,  and  am  now 
very  sure  I  shall  never  do  it  unless  it  be  on  a  dead  body." 

The  mortality  after  this  operation  has  l)ecn  already  con- 
sidered (page  316). 

In  designing  the  operation  in  any  particular  case,  allow- 
ance must  be  made  for  the  great  retractility  of  the  skin  in 


AMPUTATION  AT   THE  HIP-JOINT.  525 

tliis  part  of  tlie  limb,  and  for  the  contraction  of  the  divided 
muscles. 

The  artificial  limb  worn  after  the  operation  must,  of 
course,  take  its  support  from  the  pelvis,  and  principally  from 
the  ischium.  It  is  well,  therefore,  that  there  should  be  a 
good  internal  flap,  and  that  the  cicatrix  should  be  removed 
from  the  tuber  ischii.  At  the  same  time,  the  operation 
wound  must  be  so  arranged  as  to  allow  for  efficient  drainage. 

In  this  amputation  no  little  value  must  attach  to  methods 
of  operation  which  can  be  eft'ected  with  rapidity. 

Anatomical  Points.— The  following  landmarks  may  be 
noted : — The  pubic  spine  is  on  a  level  with  the  great 
trochanter.  The  summit  of  the  great  trochanter  is  on  a 
level  with  the  centre  of  the  hip-joint.  The  gluteal  fold  is 
some  way  above  the  lower  margin  of  the  gluteus  maximus 
muscle,  with  which  it  does  not  correspond. 

The  subcutaneous  tissue  about  the  hip  is  lax. 

The  following  are  the  muscles  attached  to  the  upper  third 
of  the  femur  : — The  three  sflutei,  the  two  obturator  muscles, 
the  two  gemeUi,  the  pyriformis,  the  psoas  and  iliacus,  the 
pectineus,  the  adductor  brevis  and  adductor  magnus,  the 
quadratus  femoris,  and  portions  of  the  vasti  and  ciiu'eus. 

The  remaining  muscles  divided  in  the  operation  are  the 
tensor  vaginae  femoris,  the  rectus,  the  sartorius,  the  gracilis, 
the  adductor  longus,  and  the  three  hamstring  muscles. 

Several  bursse  exist  about  the  hip,  the  largest  and  most 
noteworthy  being  one  between  the  great  trochanter  and  the 
gluteus  maximus,  and  another  between  that  muscle  and  the 
vastus  externus. 

The  hip  capsule  is  thickest  in  front,  at  the  site  of  the  ilio- 
femoral ligament.  It  may  here  measure  one-fourth  of  an 
inch  in  section. 

The  femoral  artery  is  separated  from  the  capsule  of  the 
hip  by  the  psoas  muscle,  upon  which  it  lies.  The  profunda 
arises  one  inch  and  a  haK  below  Poupart's  ligament ;  the 
internal  and  external  circumflex  arteries  two  inches  below 
that  ligament.  At  the  apex  of  Scarpa's  triangle — some  three 
to  four  inches  below  Poupart's  line — the  great  vessels  have  the 
following  relation  to  one  another  from  before  backwards : 
femoral  artery,  femoral  vein,  profunda  artery,  profunda  vein. 


526  OPERATIVE    SURGEBY. 

The  profunda  is  about  the  size  of  the  brachial  artery, 
the  external  circumflex  of  the  ulnar,  the  internal  circumflex 
of  the  lingual. 

The  last-named  vessel  runs  horizontally  backwards  through 
the  substance  of  the  limb,  about  the  level  of  the  lesser 
trochanter.     It  gives  a  branch  to  the  hip-joint. 

The  external  circumflex  artery  passes  more  or  less  directly 
outwards. 

The  first  perforating  artery  runs  backward  at  the  lower 
border  of  the  pectineus  muscle. 

The  sciatic  artery  gives  off  numerous  branches,  most  of 
which  are  cut  in  the  amputation.  The  comes  nervi  ischiadici 
— the  terminal  part  of  the  vessel — is  the  size  of  the  supra- 
orbital artery. 

No  large  branch  of  the  gluteal  artery  is  divided,  although 
the  inferior  branch  of  the  deep  division  will  be  cut  near  its 
extremity. 

The  obturator  artery  itself  is  not  concerned  in  the  opera- 
tion, and  the  branches  of  it  which  are  divided  are  very  small 
e.g.,  the  branches  to  the  adductors  and  to  the  hip. 

In  the  hollow  on  the  inner  side  of  the  great  trochanter 
is  an  anastomotic  network  which  is  derived  from  the 
gluteal,  sciatic,  internal  circumflex,  and  first  perforating 
arteries. 

Mode  of  Controlling  Haemorrhage  during  the  Opera- 
tion. 

Various  methods  have  been  adopted  for  preventing  ex- 
cessive hsemorrhage  during  this  disarticulation. 

1.  The  femoral  artery  may  be  ligatured  either  before  the 
flaps  are  cut  (page  534)  or  during  the  fashioning  of  the  flaps 
when  the  incision  crosses  the  line  of  the  artery,  as  in  the 
method  known  as  the  "  anterior  racket "  (page  537). 

The  procedure  involves  a  little  time,  and,  when  a  special 
incision  has  to  be  made,  somewhat  complicates  the  operation. 
The  method,  however,  has  many  advantages.  It  has  been 
urged  that  the  artery  is  apt  to  be  secured  unnecessarily  high 
up,  and  that  the  vitality  of  the  main  flap  may  be  in  con- 
sequence impaired ;  but  this  objection  has  not  been  confirmed 
by  practice. 

The   femoral    may   be   compressed    in    the   flap   by   the 


AMPUTATION  AT  THE  HIP-JOINT.  527 

iingers  of  an  assistant,  who  grasps  the  hase  of  the  flap  j'vist 
before  the  vessels  are  divided.  This  method  is  illustrated  in 
the  amputation  by  transfixion  (page  540). 

Some  surgeons  advise  digital  compression  of  the  femoral 
or  external  iliac.  This  can,  however,  hardly  be  carried  out 
except  in  a  child.  The  fingers  are  very  apt  to  slip  during 
the  manipulation  of  the  limb. 

In  all  these  methods  it  is  needless  to  say  that  the 
securing  of  the  femoral  does  not  affect  hsemorrhage  from  the 
branches  of  the  internal  iliac  artery. 

2.  Lister's  aortic  tourniquet  has  been  employed.  The  use 
of  this  instrument  is  now  no  longer  advised  by  its  author. 
It  cannot  be  used  in  stout  or  very  muscular  subjects.  It  is 
very  difficult  to  maintain  in  position,  and  is  apt,  if  firmly 
applied,  to  do  damage  to  the  intestine. 

3.  Davy's  lever  for  compressing  the  common  iliac  through 
the  rectum  has  been  extensively  used  in  this  operation.  It 
consists  of  a  smooth  rod  or  cylinder  of  ebony-wood  or  metal, 
from  eighteen  to  twenty  inches  in  length,  and  terminating  in 
a  conical  blunt  extremity.  Oil  having  been  injected  into  the 
bowel,  the  conical  or  larger  end  of  the  lever  is  introduced  into 
the  rectum,  and  is  passed  in  the  direction  of  the  vessel  to  be 
compressed.  The  surgeon,  feeling  the  end  of  the  instrument 
through  the  abdominal  parietes,  directs  it  to  the  common  iliac 
as  it  lies  on  the  pelvic  brim.  The  handle  of  the  instrument 
is  now  carried  to  the  thigh  of  the  opposite  side,  and  is  then 
raised  so  that  it  may  act  as  a  lever,  for  which  the  anus  serves 
as  a  fulcrum. 

Mr.  Davy  (British  Medical  Journal,  vol.  ii.,  1879,  page  685) 
claims  that  this  instrument  is  most  efficient — as  proved  by  a 
number  of  cases — that  it  is  simple  and  readily  applied,  and  is 
easily  maintained  in  position.  The  following  objections  may, 
however,  be  urged  against  this  ingenious  compressor: — The 
assistant  who  manipulates  it  is  a  little  in  the  way  of  the 
surgeon  and  of  those  who  are  taking  part  in  the  operation. 
The  lever  could  scarcely  be  applied  in  cases  where  no  meso- 
rectum  existed.  It  is  of  course  useless  if  the  coats  of  the 
rectum  are  unsound.  Sir  Joseph  Lister  mentions  "  a  case  in 
Avhich  a  gentleman  specially  conversant  with  the  use  of  the 
lever  failed  to  bring  it  into  eft'ective  action,  and  another  case 


528  OPERATIVE    SURGERY. 

.  .  .  where  death  resulted  from  mischief  done  by  the  end 
of  the  rod  working  in  the  dark." 

4.  The  elastic  tourniquet  furnishes  without  doubt  an 
efficient  means  of  controlling  bleeding  during  this  operation. 

The  band  may  be  applied  either  over  the  abdominal  aorta 
or  around  the  extreme  upper  part  of  the  hmb.  Its  apphcation 
in  the  former  situation  is  thus  described  by  Sir  Joseph  Lister 
("  Holmes'  System  of  Surgery,"  vol.  iii.,  page  722)  : — "  For 
the  aorta  a  pad  of  sufficient  size,  such  as  a  pin-cushion,  ad- 
justed over  the  vessel  about  the  level  of  the  ihac  crest,  is 
pressed  down  by  elastic  bands,  which,  however,  ought  not  to 
encircle  the  body  directly  and  so  cause  inconvenient  constric- 
tion of  the  waist,  but  should  be  connected  with  the  ends  of  a 
rigid  object  placed  transversely  beneath  the  back  and  extend- 
ing laterally  sufficiently  far  to  protect  the  sides  of  the  body 
from  compression.  A  narrow  piece  of  board,  with  two  lateral 
notches  at  each  end,  would  answer  the  purpose  quite  well  for 
an  emergency  as  a  substitute  for  the  curved  piece  of  stout  iron, 
with  rings  and  hooks  at  the  ends,  recommended  by  Esmarch." 

The  apphcation  of  the  elastic  band  to  the  upper  part  of 
the  thigh  is  thus  described  by  Mr.  Jordon  Lloyd  {Lancet, 
voL  L,  1883,  page  897)  :— 

"  The  limb  about  to  be  operated  upon  should  first  be 
emptied  of  blood  by  elevation.  This  will  occupy  only  a  feAv 
minutes,  and  may  be  executed  during  the  administration  of 
the  anaesthetic.  A  strip  of  black  india-rubber  bandage  about 
two  yards  long  is  to  be  doubled  and  passed  between  the 
thighs,  its  centre  lying  between  the  tuber  ischii  of  the  side  to 
be  operated  on  and  the  anus.  A  common  calico  thigh-roller 
must  next  be  laid  lengthways  over  the  external  iliac  arter}-. 
The  ends  of  the  rubber  are  now  to  be  firmly  and  steadily 
drawn  in  a  direction  upwards  and  outwards,  one  in  front  and 
one  behind,  to  a  point  above  the  centre  of  the  iliac  crest 
of  the  same  side.  They  must  not  be  pulled  tight  enough  to 
check  pulsation  in  the  femoral  artery.  The  front  part  of  the 
band,  passing  across  the  compress,  occludes  the  external  iliac, 
and  runs  parallel  to  and  above  Poupart's  ligament.  The 
back  half  of  the  band  runs  across  the  great  sacro-sciatic  notch, 
and,  by  compressing  the  vessels  passing  through  it,  prevents 
bleeding  from  the  branches  of  the  internal  ihac  artery. 


AMPUTATION  AT   THE  II IP- JOINT.  529 

"  The  ends  of  the  bandage  thus  tightened  must  be  held  by 
the  hand  of  an  assistant,  placed  just  above  the  centre  of  the 
iliac  crest,  the  back  of  the  hand  being  against  the  surface  of 
the  patient's  body.  In  this  way  an  elastic  tourniquet  is 
made  to  encircle  one  of  the  innominate  bones,  checking  the 
whole  blood-supply  to  the  lower  extremity.  When  the  band 
is  once  properly  adjusted,  the  assistant  has  only  to  take  care 
that  it  does  not  slip  away  from  the  compress  or  over  the 
tuber  ischii.  The  former  is  prevented  by  securing  pad  and 
tourniquet  together  with  a  stout  safety-pin,  and  the  latter  by 
keeping  the  securing  hand  well  above  the  iliac  crest ;  and  even 
more  safely  by  looping  a  tape  beneath  the  elastic  near  the 
tuber  ischii,  passing  it  behind  under  the  sacrum,  and  having  it 
held  in  that  position.  The  solid  rubber  tourniquet  may  be 
used  instead  of  this  bandage.  I  prefer,  however,  the  bandage. 
The  soft  parts  are  less  damaged  by  reason  of  its  greater 
breadth,  and  it  is  less  likely  to  roll  off  the  compress  placed 
over  the  external  ihac. 

"  The  hgature,  being  altogether  above  the  limb,  is  out  of 
the  way  of  the  surgeon  in  any  operation  at  or  about  the  hip- 
joint.  The  great  trochanter  is  fully  exposed,  the  hip  being 
free  upwards  as  far  as  the  iliac  crest,  and  inwards  to  the 
perineum.  The  plan  is  applicable  to  amputation  by  transfixion 
or  to  excision  of  the  joint." 

5.  The  use  of  long  needles  or  skewers  has  been  advised  or 
adopted  by  a  few  operators.  Trendelenburg  transfixes  the  thigh 
by  a  single  needle  passed  in  fr-ont  of  the  neck  of  the  femur 
and  beneath  the  vessels.  Over  the  ends  of  the  needle  and  in 
front  of  the  thigh  a  compressing  rubber  cord  is  carried.  Mr. 
Myles  (Brit.  Med.  Journ.,  Nov.  9,  1889)  advises  the  following 
method  : — A  stout  steel  skewer  is  thi'ust  straight  through  the 
thigh  from  before  backwards.  Its  point  enters  an  inch  below 
Poupart's  ligament,  and  just  to  the  outer  side  of  the  femoral 
artery  it  passes  to  the  inner  side  of  the  neck  of  the  femur,  and 
emerges  a  Kttle  above  the  gluteal  fold.  An  india-rubber  cord 
is  now  passed  in  the  form  of  a  figure  of  8  around  the  project- 
ing ends  of  the  skewer.  The  amputation  is  effected  by  means 
of  lateral  flaps. 

Dr.  Wyeth  (Internat  Journ.  of  Surg.,  July,  1890)  uses  two 
needles  for  the  purpose  of  fixing  an  Esmarch's  band  in  position. 


530  OPERATIVE    SUBGEUY. 

Two  steel  mattress-needles,  three-sixteenths  of  an  inch  in 
diameter  and  a  foot  long,  are  used.  The  point  of  one  is 
inserted  an  inch  and  a  half  below,  and  just  to  the  inner  side 
of,  the  anterior  superior  ihac  spine,  and  is  made  to  traverse 
the  muscles,  passing  about  half-way  between  the  great  tro- 
chanter and  the  iliac  spine,  external  to  the  neck  of  the  femur, 
and  coming  out  just  behind  the  trochanter. 

The  point  of  the  second  needle  is  entered  an  inch  below 
the  level  of  the  groin  internal  to  the  saphenous  opening,  and, 
passing  through  the  adductors,  comes  out  about  an  inch  and 
a  half  in  front  of  the  tuber  ischii.  No  vessels  are  endangered 
by  these  needles.  The  points  are  protected  by  corks,  to  pre- 
vent injury  to  the  operator's  hands. 

A  piece  of  strong  white  rubber  tube  half  an  inch  in 
diameter,  and  long  enough  when  tightened  in  position  to  go 
five  or  six  times  around  the  thigh,  is  now  wound  very  tightly 
around  and  above  the  fixation  needles,  and  tied. 

The  amputation  is  then  carried  out  by  means  of  the  cir- 
cular method.  This  method  must  of  course  be  credited 
with  the  objections  which  have  been  urged  against  the  elastic 
tourniquet.  If  the  after-oozing  be  taken  into  account,  opera- 
tions conducted  as  above  described  cannot  be  regarded  as 
"  bloodless." 

Precautions  against  Shock. — Every  provision  must  be 
taken  against  shock.  The  limbs  should  be  well  wrapped  up, 
the  body  enveloped  in  a  blanket,  and  the  head  kept  low.  A 
stinmlant  may  be  given  before  the  operation,  and  means 
should  be  at  hand  to  administer  brandy  by  enema  or  subcu- 
taneous injection  if  required. 

Methods  of  Operating. — The  different  methods  advised 
by  different  surgeons  for  amputating  at  the  hip-joint  are 
exceedingly  numerous.  Farabeuf  gives  figures  of  no  less  than 
twenty-five  different  procedures,  and,  if  each  operation  were  to 
be  named  after  the  surgeon  designing  it,  it  would  be  necessary 
to  describe  some  forty  methods  of  disarticulation  at  the 
hip. 

Many  of  these  operations  have  long  since  been  abandoned, 
and  many  differ  from  one  another  but  in  very  trifling 
particulars. 

In  the  accouQt  which  follows  it  is  only  possible  to  deal 


AMPUTATION  AT   THE  HIP-JOINT.  531 

with  certain  typical  methods  without  attempting  to  pursue 
the  individual  modifications  of  particular  surgeons. 

The  following  modes  of  performing  this  amputation  will 
be  described — 

1.  Disarticulation   through    an    external    racket    in- 

cision. 

2.  Disarticulation  through  an  anterior  racket  incision. 

3.  Disarticulation    by   antero-posterior    flaps    (trans- 

fixion). 

4.  Guthrie's  operation. 

1.  Disarticulation  through  an  External  Racket  Inci- 
sion.— Under  this  title  may  be  grouped  the  modified  oval 
method  with  the  summit  of  the  incision  on  the  outer  side,  the 
"  raquette  a  queue  trochanterienne,"  and  the  amputation  by 
combined  circular  and  vertical  incisions  (the  vertical  cut 
being  external).  These  are  the  operations  associated  with 
the  names  of  Ravaton,  Kerr,  Foullioy,  Malgaigne,  Cornuau, 
Scoutteten,  Fumeaux  Jordan,  Lister,  Esmarch,  and  others. 

Instruments. — The  elastic  tourniquet  already  described; 
a  stout  amputatmg-knife  with  a  blade  some  six  inches  in 
length,  and  with  not  too  fine  a  point ;  a  large  stout  scalpel 
or  resection  knife  ;  an  amputating-saw ;  lion  forceps  if  the 
bone  is  to  be  divided  {see  Esmarch's  operation,  page  535) ; 
artery  forceps ;  pressure  forceps ;  dissecting  forceps  ;  scissors, 
long  needles,  etc.  If  the  operation  is  to  be  subperiosteal, 
a  periosteal  elevator  or  rugine  is  required. 

Position. — The  body  is  drawn  down  until  the  pelvis  rests 
upon  the  extreme  lower  edge  of  the  table.  The  sound  limb 
is  secured  out  of  the  way.  The  patient  is  turned  sufficiently 
over  on  the  sound  side  to  expose  the  postero-extemal  aspect 
of  the  limb  to  be  removed.  Some  care  has  to  be  taken 
to  prevent  the  patient  from  slipping  entirely  off  the  table. 
The  surgeon  stands  on  the  outer  side  of  the  thigh — in  the 
case  of  both  the  right  and  the  left  extremities — and  faces  the 
patient. 

In  the  case  of  the  left  limb  it  may  be  sometimes  more 
convenient  to  stand  on  the  inner  side  of  the  thisfh,  between 
the  limbs. 

The  assistant  standing  above  the  surgeon  attends  to  the 
tourniquet  and  supports  the  flap  during  the  ligaturing  of  the 
I  I  2 


532  OPERATIVE    SURGEBY. 

vessels  after  the  tourniquet  has  been  removed.  Another 
assistant  manipulates  the  hmb,  while  a  third,  standing  oppo- 
site to  the  surgeon,  attends  to  the  sponging  and  assists  in  the 
disarticulation,  in  the  fashioning  of  the  flaps,  and  in, securing 
the  vessels. 

The  Operation. — 1.  The  hmb  being  adducted  and  a 
httle  flexed  and  rotated  in,  the  knife  is  entered  about  two 
inches  above  the  upper  edge  of  the  great  trochanter,  and  is 
carried  vertically  down  the  limb  along  the  posterior  border 
of  the  trochanter  for  about  seven  inches.  The  knife  is  now 
drawn  across  the  limb  in  front  and  behind  in  the  form  of  two 
crescentic  incisions,  which  meet  on  the  inner  side  of  the 
thigh  some  httle  way  below  the  termination  of  the  vertical 
incision,  and  some  inches  below  the  genito-crural  angle.  The 
whole  of  this  extensive  cut  should  at  first  involve  only  the 
skin  and  the  subcutaneous  tissues.  At  the  outer  aspect  of  the 
limb  the  incision  forms  a  large  inverted  Y  (Fig.  145,  c).  While 
the  obhque  incision  is  being  made,  the  assistant  may  rotate 
the  thigh  a  little  so  as  to  make  the  tissues  meet  the  surgeon's 
knife. 

2.  The  surgeon  now  turns  to  the  oblique  incision  en- 
circhng  the  thigh,  and  separates  the  skin  and  subcutaneous 
tissues  all  round  until  these  parts  have  been  raised  to  the 
extent  of  about  two  inches. 

This  is  eft'ected  precisely  as  in  the  ordinary  circular  opera- 
tion, the  limb  being  rotated  as  required. 

8.  The  thigh  being  now  again  adducted,  rotated  in  and  a 
httle  flexed,  the  knife  is  carried  well  down  to  the  femur  along 
the  whole  length  of  the  vertical  incision. 

The  muscles  attached  to  the  great  trochanter  must  next 
be  divided  close  to  the  bone.  The  anterior,  superior,  and 
posterior  borders  of  the  trochanter  should  be  cleared  in  order, 
■  The  first  muscle  to  be  divided  is  the  gluteus  medius,  attached 
to  the  outer  surface  of  the  process.  The  obturator  externus 
tendon  is  apt  to  escape  division  as  it  dips  into  the  digital 
fossa.  In  clearing  the  process  the  limb  must  be  kept  ex- 
tremely adducted  and  well  rotated  in.  A  short  stout  knife — 
such  as  is  used  in  Syme's  amputation  or  in  resection  opera- 
tions— is  very  convenient  at  this  stage.  The  knife  must  be 
carried  vigorously  down  to  the  bone 


AMPUTATION  AT   THE  HI  I'- JOINT.  533 

The  upper  part  of  the  shaft  of  the  femur  is  now  cleared 
as  far  as  the  vertical  incision  extends.  The  soft  parts  must 
be  liberally  cut,  care  being  taken  that  the  femoral  and  pro- 
funda arteries  are  not  encroached  upon. 

In  this  step  the  insertions  of  the  gluteus  maximus, 
quadratus  femoris,  psoas,  iliacus,  pectineus  and  upper  adductor 
fibres  are  divided,  together  with  the  superior  portions  of  the 
triceps  femoris.  The  surgeon  is  aided  by  an  assistant,  who 
draws  the  divided  soft  parts  away  so  as  to  well  expose  the  bone. 

4.  The  bone  has  now  to  be  disarticulated.  The  capsule 
may  be  divided  transversely  at  its  upper  and  posterior  parts 
while  the  Umb  is  in  the  position  of  extreme  adduction.  The 
anterior  part  of  the  capsule  can  be  severed  while  the  thigh  is 
a  httle  flexed. 

The  limb  is  now  rotated  outwards  to  its  utmost,  the  joint 
opened,  and  the  round  ligament  cut. 

Everything  about  the  upper  end  of  the  femur  should  now 
be  free  and  ready  for  the  final  sw^eep  of  the  knife. 

Up  to  this  point  no  vessels  of  any  magnitude  have  been 
divided,  the  chief  arteries  concerned  being  the  internal  cir- 
cumflex, some  brandies  of  the  external  circumflex  and  of 
the  sciatic,  and  a  few  muscular  vessels. 

5.  Nothing  now  remains  but  to  cut  the  muscles  upon  the 
inner  side  of  the  limb  by  a  vigorous  circular  sweep  of  the 
knife  at  the  level  of  the  already  retracted  skin.  A  few 
touches  of  the  blade,  and  the  limb  is  removed. 

The  great  vessels  are  at  once  secured. 

If  the  operation  is  to  be  "subperiosteal"  the  femur  is 
stripped  of  periosteum  by  means  of  the  elevator,  the  muscles 
bemg,  so  far  as  is  possible,  detached  with  it.  This  separation 
cannot  be  followed  further  than  the  base  of  the  femoral  neck, 
and  involves  a  considerable  expenditure  of  time.  Along  the 
linea  aspera  the  detachment  of  the  periosteum  is  exceedingly 
difiicult.  The  value  of  this  modification  of  the  more  ready 
method  is  discussed  later. 

Hoemorrhage. — In  securing  the  bleeding  points  the  assist- 
ant holds  up  the  anterior  part  of  the  flap,  so  as  to  well 
expose  the  whole  wound-surface.  Care  must  be  taken  that 
the  tourniquet  does  not  slip  when  the  limb  is  removed. 

The  o-reat  vessels  are  found  severed  on  the  anterior  face 


534  OPERATIVE    SURGERY. 

of  the  woimd,  close  to  the  divided  rectus,  sartorius,  and 
adductor  longus  muscles. 

The  vessels  are  placed  one  behind  the  other  in  the  fol- 
lowing order,  from  before  backwards  : — The  femoral  artery,  the 
femoral  vein,  the  profunda  vein,  the  profunda  artery. 

The  first  vessel  to  be  sought  for  after  the  main  trunks  are 
ligatured  is  the  internal  circumflex.  It  will  be  found  divided 
in  the  tissues  about  the  inner  and  posterior  side  of  the 
acetabulum.  The  branches  of  this  artery  often  give  much 
trouble.  The  descending  branch  of  the  external  circumflex  is 
found  cut  close  to  the  inner  edge  of  the  vastus  externus. 
The  transverse  branch  of  that  artery  will  also  probably 
require  a  ligature. 

In  the  posterior  segment  of  the  wound  the  comes  nervi 
ischiadici  is  early  recognised,  and  will  require  ligature. 

Bleeding  will  occur  from  other  branches  of  the  sciatic 
artery,  and  from  many  muscular  branches  distributed  about 
the  surface  of  the  wound. 

Varieties  of  the  Operation. — The  first  operation  designed 
for  the  removal  of  the  lower  limb  at  the  hip-joint  was  in  all 
essential  points  identical  with  that  just  described.  The 
surgeon  was  Ravaton,  the  date  1743. 

The  amputation  also  performed  by  Kerr,  of  Northampton, 
in  1778,  was  practically  upon  the  same  lines. 

Kerr's  external  incision  was  in  the  form  of  an  inverted 
V,  and  not  of  an  inverted  Y,  as  in  the  procedure  just  detailed. 

Foulhoy  employed  the  external  racket  incision  in  1841, 
havincr  first  lisfatured  the  common  femoral  at  the  fold  of 
the  groin. 

Malgaigne's  operation  {en  raquette)  was  like  the  present 
procedure,  except  that  the  vertical  incision  was  shorter,  and 
the  circular  incision,  therefore,  more  oblique. 

The  oval  operations  of  Cornuau,  Scoutteten,  Giinther,  and 
others  may  be  placed  in  the  present  category,  and  attention 
may  be  drawn  to  the  close  resemblance  of  this  procedure 
to  the  amputation  devised  by  Guthrie  (page  541). 

The  following  methods  require  more  extended  notice : — 

(a)  Lister's. — The  above  description  of  disarticulation  at 
the  iiip  is  founded  upon  the  sketch  of  an  operation  given  by  Sir 
Joseph  Lister  ("  Holmes'  System  of  Surgery,"  vol  iii.,  page  721). 


AMPUTATION  AT   THE  HIP-JOINT. 


535 


Lister  made  the  external  incision  eight  inches  in  length  (for 
an  adult),  and  divided  the  soft  parts  around  the  inner  side 
of  the  limb  before  the  femur  was  cleared.  The  disarticulation 
of  the  bone  was  the  last  step  of  the  operation.  He  furnished 
no  directions  for  the  precise  performance  of  the  operation, 
and  founded  its  principles  upon  the  procedure  of  Furneaux 
Jordan. 

(b)  Furneaux  Jordan's. — Mr.  Jordan  ("  Surgical  Enquiries," 
second  ed.,  page  303)  gives  the  following  description  of  his 
operation : — "  A  straight  incision  was  made,  and  the  trochan- 
ters and  upper  part  of  the  shaft  were  freed 

from  theu'  muscular  attachments,  after  which 
the  capsule  was  opened.  Next,  the  shaft 
was  cleared  downwards  from  all  its  attach- 
ments for  a  considerable  distance,  and  then 
a  few  free  sawing  movements,  wdth  a  long- 
bladed  knife,  through  the  thigh,  from  which 
the  bone  had  been  removed,  ended  the  oper- 
ation. The  integuments  were  simply  drawn 
upwards,  and  the  soft  parts  were  cut  straight 
through.  No  bone  being  left,  the  muscles 
quickly  retracted,  and  were  easily  covered  by 
the  skin.  Very  Httle  blood  was  lost.  .  ,  . 
The  principle  of  the  operation  may  be  thus 
described : — First  enucleate  the  bone,  then 
cut  through  the  limb  at  any  desired  spot — 
the  middle  of  the  thigh,  or  below,  or  even 
near  the  knee." 

It  is  evident  from  this  description,  and 
fi'om  the  diagram  of  the  operation  given  by 
Mr.  Jordan  {see  Fig.  147),  that  his  disarticu- 
lation differs  very  considerably  from  the  pro- 
cedures associated  with  his  name  by  more  than  one  writer. 

(c)  Esmarch's. — This  method  is  identical  with  that  de- 
scribed by  Veitch,  Lacauchie,  Volkmann,  and  others. 

Mr.  Barker  ("  Manual  of  Surgical  Operations,"  1887)  gives 
the  followiug  account  of  Esmarch's  operation,  in  favour  of 
which  he  speaks  : — 

"  By  a  single,  strong,  muscular  sweep  of  the  Imife  five  inches 
below  the  tip  of  the  trochanter,  all  the  soft  parts  of  the  thigh 


Fig.  l-i7.--FUEXEAUX 

joedan's  amputa- 
tion AT  THE  HIP- 
JOINT  ("  Surgical 
Enquiries,"  Plate 
X.,page2S.S).  The 
shaded  part  repii  - 
sents  the  area  tra- 
versed by  the 
knife  :  the  dotted 
lines  the  incision. 


636  OPERATIVE    SUBGEBY. 

are  divided  completely  to  the  bone,  and  the  latter  is  at  once 
sawn  across. 

"  The  vessels  are  then  ligatured. 

"The  bone  is  now  seized  in  a  lion  forceps  and  steadied, 
while  a  second  incision  is  made,  commencing  two  inches 
above  the  tip  of  the  trochanter,  and  carried  down  along  the 
latter,  to  terminate  in  the  first  circular  cut.  The  two  borders 
of  this  incision  being  held  apart  by  an  assistant,  the  bone  is 
cleared  of  the  soft  parts  by  the  use  of  an  elevator  inserted 
under  the  periosteum,  and  by  the  knife  where  the  muscle- 
insertions  are  too  firm  for  the  latter.  When  the  capsule  is 
reached  it  is  divided,  and  the  head  is  dislocated  in  the 
usual  way." 

2.  Disarticulation  through  an  Anterior  Racket  Incision. 

This  method  is  also  loiown  as  the  anterior  oval  method. 

It  is  founded  upon  the  operations  performed  by  Larrey  in 
1793,  by  Sir  Astley  Cooper  in  1824,  by  Roser  in  1856,  and 
later  by  Yerneuil.  In  the  account  of  the  operation,  the 
admirable  description  of  Farabeuf  is  followed. 

The  same  instruments  are  required  as  are  used  in  the 
previous  operation.  In  addition  to  those  mentioned,  an 
aneurysm  needle  and  a  small  scalpel  will  be  needed.  Retrac- 
tors are  occasionally  employed. 

The  position'  of  the  surgeon  and  of  his  assistants  is  the 
same.  The  patient  is  so  placed  that  the  pelvis  rests  upon 
the  extreme  end  of  the  table,  and  the  trunk  evenly  upon  the 
back. 

T?te  Operation. — 1.  No  tourniquet  is  applied.  The  inci- 
sion is  commenced  at  the  centre  of  Poupart's  ligament, 
and  is  carried  downward  along  the  course  of  the  femoral 
vessels  for  about  three  inches.  It  is  then  made  to  curve 
inwards  so  as  to  cross  the  adductors  about  four  inches  below 
the  genito-crural  fold.  The  knife  then  sweeps  over  tlie 
posterior  aspect  of  the  thigh,  crosses  the  outer  side  of  the 
limb  a  little  way  below  the  base  of  the  great  trochanter,  and 
is  carried  obliquely  across  the  anterior  aspect  of  the  thigh 
to  meet  the  vertical  incision  about  two  inches  below  its  point 
of  commencement  (Fig.  148). 

This  incision  concerns  at  first  only  the  skin  and  the 
subcutaneous  tissue.     It  cannot  be  made  with  one  sweep  of 


AMPUTATION  AT  THE  HIP-JOINT. 


537 


the  knife,  and  the  limb  must  be  so  held  and  so  rotated  as  to 
make  the  tissues  meet  the  knife. 

2.  The  femoral  sheath  is  now  exposed  at  the  upper  part 
of  the  incision,  and  the  vessels  are  laid  bare  by  dissection. 
The  common  femoral  artery  is  ligatured  in  two  places  close 
together,  and  is  divided  between  the  hgatures.  The  femoral 
vein   is   secured  in  the  same 

manner,  and  then  cut  across        . 
at  the  same  level  as  the  artery. 

3.  The  skin  is  freed  all 
round  the  whole  length  of  the 
incision,  and  is  allowed  to 
retract  a  Httle.  The  integu- 
ments, however,  are  not  es- 
pecially dissected  up. 

4.  The  stout  scalpel  is  now 
taken,  and  is  carried  through 
the  muscles  in  the  outer  flap. 
In  this  way  are  divided  the 
sartorius,  the  rectus,  and  the 
tensor  vaginae  femoris.  Tlie 
retraction  of  these  muscles  will 
expose  the  external  cii-cumflex 
artery,  which  is  secured  be- 
tween two  ligatures  and  divided 

Carry  the  knife  backwards,  rotate  the  limb  in,  and  divide 
the  insertion  of  the  gluteus  maximus.  Rotate  the  limb  out 
and  divide  the  psoas  muscle.  At  this  point  the  internal 
circumflex  artery  is  exposed,  secured,  and  divided.  Retractors 
are  of  use  at  this  stage  of  the  operation, 

5.  The  muscles  in  the  inner  flap  are  now  cut  at  the  level 
of  the  retracted  skin.  These  include  the  pectineus,  the 
gracilis,  and  the  superficial  adductors.  Any  divided  vessels 
are  secured. 

6.  Adduct  the  thigh,  and  rotate  it  inwards  so  as  to 
expose  the  great  trochanter.  Divide  the  insertions  of  the 
muscles  attached  to  this  process,  notably  the  gluteus  minimus 
and  medius. 

7.  Abduct  the  limb  and  rotate  it  out.  Incise  the  capsule 
transversely.     Disarticulate.     Divide  the  round  ligament  and 


Tig.  148.^DISARTICTrLATION  AT  THE 
HIP-JOINT  BY  AN  ANTEEIOE  EACKEl 
INCISION. 


538  OPERATIVE    SUUGEBY. 

also  the  obturator  externus  tendon,  if  it  lias  up  to  the  present 
escaped  division. 

8.  The  limb  being  still  more  rotated  outwards,  the  head 
of  the  femur  is  dragged  forward,  and  the  longer  knife  being 
passed  behind  the  bone,  all  the  soft  parts  at  the  j^osterior 
aspect  of  the  limb  are  divided  with  one  sweep  of  the  blade 
at  the  level  of  the  retracted  skin.  These  tissues  will  include 
the  hamstrings,  the  great  sciatic  nerve,  and  the  undivided 
parts  of  the  adductors,  principally  represented  by  the  adductor 
mao^nus. 

When  the  wound  is  approximated,  there  should  be  no 
strain  upon  the  sutures,  which  are  deeply  apphed. 

Hieriiorrhage. — It  is  a  feature  of  this  operation  that  the 
vessels  are  Hgatured  as  they  are  exposed,  the  surgeon  deahng 
with  the  haemorrhage  according  to  the  method  adopted 
during  the  removal  of  a  large  tumour.  In  my  experience  of 
this  operation  the  loss  of  blood  has  been  quite  insignificant. 

3.  Disarticulation  by  Antero-Posterior  Flaps  (Trans- 
fixion). 

This  operation  was  at  one  time  very  extensively  practised 
in  England.  The  method  is  fi*equently  known  as  Listen's 
operation.  It  has  been  very  well  described  by  Fergusson, 
and  has  been  associated  with  the  names  of  many  French 
surgeons. 

The  great  feature  of  the  operation  consists  in  the  rapidity 
with  which  it  can  be  performed.  Fergusson  states  that  the 
procedure  can  be  completed  (so  far  as  the  use  of  the  knife  is 
concerned)  in  from  twelve  to  twenty  seconds. 

This  was  a  matter  of  no  little  moment  before  the  days 
of  ether  and  chloroform. 

The  anterior  flap  is  long  and  U-shaped.  The  posterior 
flap  is  shorter,  and  is  more  squarely  cut. 

No  tourniquet  of  any  kind  is  employed.  Even  the  elastic 
band  would  be  in  the  way,  and  would  probably  shp  during 
the  somewhat  vig(jrous  movements  to  which  the  limb  is 
subjected.  The  main  vessels  are  secured  in  the  flap  itself 
by  the  fingers  of  an  assistant,  who  compresses  them  during 
the  actual  cutting  of  the  flap. 

Instruments.  —  A  pointed  amputating-knife,  having  a 
length  equal  to  one  and  a  half  times  the  diameter  of  the  limb 


AMPUTATION  AT   THE  HIP- JOINT.  539 

at  the  level  of  the  hijx  Artery  forceps.  Ten  or  fifteen 
pressure  forceps.     Scissors,  needles,  etc. 

Position. — The  patient  is  supine,  and  the  buttocks  rest 
upon  the  extreme  edge  of  the  table.  The  sound  limb  is 
secured  out  of  the  way.  The  surgeon  stands  to  the  outer 
side  of  the  limb  in  the  case  of  both  the  right  and  the  left 
extremities.  One  assistant  stands  above  the  operator.  His 
duty  is  to  attend  to  the  anterior  flap,  to  compress  the  main 
vessels  as  the  flap  is  being  cut,  and  to  hold  it  out  of  the 
way  during  the  disarticulation.  A  second  assistant  stands 
opposite  to  the  surgeon  to  assist  generally,  and  to  seize 
any  bleeding  points  as  soon  as  the  limb  is  separated.  A 
third  helper  may  stand  near  the  patient's  shoulders  (on  the 
opposite  side),  to  steady  the  pelvis  and  prevent  the  body 
from  shpping  oft'  the  table.  The  fourth  assistant  manipulates 
the  limb.  This  office  is  of  exceeding  importance.  The 
rapidity  with  which  the  disarticulation  can  be  effected 
depends  largel}^  upon  the  smartness  of  this  assistant. 

The  limb  is  made  to  assume  a  different  position  at  each 
step  of  the  operation. 

1.  The  limb  is  a  httle  flexed  and  a  little  abducted.  The 
knife  is  entered  midway  between  the  anterior  superior  ihac 
spine  and  the  top  of  the  great  trochanter,  is  thrust  through 
the  limb  parallel  with  Poupart's  ligament,  and  is  brought  out 
at  the  inner  side  of  the  thigh  behind  the  adductor  longus, 
about  one  inch  in  front  and  one  inch  below  the  tuber  ischii, 
and  some  three  inches  from  the  anus. 

The  knife  should  graze  the  head  of  the  femur  in  its 
passage,  and  j  ust  open  the  hip  capsule.  It  is  passed,  therefore, 
as  deeply  as  possible. 

If  reasonable  care  be  not  taken,  the  knife  may  slice  the 
femoral  vessels,  or  may  be  arrested  by  the  femur,  or  may 
enter  the  thyroid  foramen,  or  may  have  its  point  driven  into 
the  testicle  or  the  thigh  of  the  opposite  side. 

The  surgeon  now  cuts,  by  a  sawing  movement  of  the  knife, 
a  U-shaped  anterior  flap  some  eight  inches  in  length. 

This  flap  will  end  about  the  junction  of  the  upper  with  the 
middle  thirds  of  the  thigh  (Fig.  146,  b).  It  should  include  as 
much  of  the  soft  parts  as  possible. 

It  will  be  noticed  that  the  knife  is  placed  obUqueiy  at  the 


540  OPERATIVE    SURGERY. 

commencement  of  the  cutting  of  the  flap,  and  that  it  becomes 
transverse  at  the  termination.  More  tissue  has  to  be  divided 
on  the  outer  than  on  the  inner  side  of  the  hmb.  If  the 
flap  be  carelessly  cut,  it  is  apt  to  be  too  pointed  at  its 
extremity. 

As  the  knife  is  carried  downwards,  the  first  assistant  slips 
his  fingers  under  the  cut  surface  of  the  flap  and  compresses 
the  main  vessels  against  his  thumbs,  which  are  placed  upon 
the  skin.  It  thus  happens  that  before  the  femoral  is  divided 
at  the  end  of  the  flap  the  upper  part  of  the  trunk  is  well 
secured. 

As  soon  as  the  flap  is  made  this  assistant  draws  it  upwards 
out  of  the  surgeon's  way,  while  he  still  grasps  the  great 
vessels. 

2.  The  limb  is  straightened  and  is  fully  extended,  i.e., 
the  knee  is  depressed.     The  surgeon  cuts  open  the  capsule. 

The  thigh  is  now  rotated  outwards.  The  head  shps  out  of 
the  acetabulum,  and  the  round  ligament  is  divided. 

The  thigh,  still  extended,  is  now  rapidly  adducted  and 
rotated  inwards,  and  the  muscles  about  the  great  trochanter 
are  cut. 

The  disarticulation  is  complete,  and  nothing  remains  but  to 
cut  the  posterior  flap. 

3.  The  whole  thigh  is  now  hfted  directly  up  in  such  a 
way  that  the  free  end  of  the  femur  is  dragged  away  from  the 
posterior  tissues  and  is  forced  forwards. 

The  surgeon  passes  his  knife  behind  the  femoral  head  and 
the  great  trochanter,  and,  cutting  downwards,  forms  the 
posterior  flap. 

This  flap  is  shorter  than  the  anterior,  and  the  skin  is 
divided  about  the  level  of  the  gluteal  fold  (Fig.  146,  b). 

The  clearing  of  the  great  trochanter  is  perhaps  the  most 
difficult  part  of  the  operation.  If  not  well  done,  a  pocket  is 
left  in  the  flap  at  the  site  of  that  process. 

Hcemorrhage. — The  sciatic  artery  and  branches  of  the 
gluteal  in  the  posterior  flap  should  first  be  secured ;  then  the 
internal  circumflex,  close  to  the  inner  side  of  the  acetabulum. 
The  superficial  femoral  is  divided  near  to  tlie  fi'ee  extremity  of 
the  anterior  flap.  The  profunda  is  usually  foimd  severed  about 
the  middle  of  the  cut  surface  of  the  flap.     In  the  outer  part  of 


AMPUTATION  AT  TEE  HIP-JOINT.  541 

tlie  same  flap  the  external  circumflex  will  be  found  and  will 
require  a  ligature. 

The  femoral  and  profunda  veins  should  be  ligatured. 

Varieties  of  the  Operation. — Some  surgeons  have  made  an 
anterior  flap  only,  cutting  the  soft  parts  at  the  back  of  the 
limb  by  a  single  sweep  of  the  knife  at  right  angles  to  the  axis 
of  the  femur. 

The  anterior  and  posterior  flaps  have  been  made  of  the 
same  length,  i.e.,  about  five  inches. 

Fergusson  made  the  anterior  flap  four  inches  in  length  and 
the  posterior  "  somewhat  longer." 

Beclard  cut  the  posterior  flap  first. 

4.  Guthrie's  Operation. 

This  is  the  best  type  of  operation  by  flaps  cut  from  without 
inwards.  The  flaps  are  short  and  oblique,  and  are  placed 
antero-posteriorly. 

Instruments. — The  elastic  tourniquet  is  appUed  in  the 
manner  akeady  described.  A  stout  knife  with  a  blade  five 
inches  in  length ;  artery  forceps ;  ten  or  fifteen  pressure 
forceps';  scissors,  etc. 

Position. — The  position  of  the  patient  and  of  the  surgeon 
and  his  assistants  is  the  same  as  in  operation  No.  1  (page 
531).  It  is  more  convenient  for  the  operator  to  stand  on  the 
rigfht-hand  side  of  either  limb. 

The  Operation. — The  following  is  Guthrie's  description 
("  Commentaries,"  5th  ed.,  1853,  page  76) : — "  The  surgeon 
commences  his  first  incision  some  three  or  four  inches  directly 
below  the  anterior  spinous  process  of  the  ilium,  carries  it 
across  the  thigh  through  the -integuments,  inwards  and  back- 
wards in  an  oblique  direction,  at  an  equal  distance  from  the 
tuberosity  of  the  ischium  to  nearly  opposite  the  spot  where 
the  incision  commenced.  The  end  of  this  incision  is  then  to 
be  carried  upwards  with  a  gentle  curve  behind  the  trochanter, 
until  it  meets  with  the  commencement  of  the  first,  the  second 
incision  beins^  about  or  rather  less  than  one-third  the  lenoth  of 
the  first. 

"  The  integuments,  including  the  fascia,  being  retracted,  the 
three  gluteal  muscles  are  to  be  cut  through  to  the  bone.  The 
Ivnife  being  then  placed  close  to  the  retracted  integuments, 
cuts   steadily  through  everything  on  the  anterior  part  and 


542 


OPERATIVE    SURGERY. 


inside  of  the  thigh.     The  femoral  or  other  large  artery  may 
then  be  drawn  out  and  tied. 

"  The  capsular  Ugament  being  well  opened,  and  the  liga- 
mentum  teres  divided,  the  knife  should  be  passed  behind  the 
head  of  the  bone  thus  dislocated,  and  made  to  cut  its  way  out, 

care  being  taken  not  to  have 
•;  too     large     a     quantity    of 

muscle  on  the  under  part, 
or  the  inteo'uments  will  not 
cover  the  wound." 

5.    Other    Methods    of 
Disarticulation.  —  Of     the 
many  other  procedures  not 
x,  here  described  it  is  necessary 

X      only  to  allude  to  the  ampu- 
tations by  lateral  Jiaps. 

These  operations  are  still 
advised  by  some  surgeons 
in  cases  of  limited  injury  of 
the  front  of  the  thigh,  as  in 


#% 


Fig.  149. — LISFEAIJC'S  DISAETICUXATION  AT 
THE  HIP  BY  INTEENAL  AND  EXTERNAL 
FLAPS. 


g-unshot  wound,  and  in  cases 


where  a  growth  projects 
towards  the  anterior  part  of 
the  limb.  Very  unwieldy  stumps  are  left,  and  these  methods 
have  httle  or  nothing  to  recommend  them. 

Figure  149  shows  the  incisions  m  Lisfranc's  7)iethod.  The 
flaps  are  cut  by  transfixion,  the  outer  one  being  made  first. 
After  disarticulation  has  been  effected  the  inner  flap  is  cut. 
The  vessels  are  ligatured  as  exposed.  Each  flap  is  about  four 
inches  in  length,  and  are  both  very  bulky. 

The  names  of  Larrey,  Blandin,  and  Dupuytren  are  especially 
associated  with  these  lateral-flap  operations. 

An  excellent  atlas  of  the  various  methods  of  amputating  at 
the  hip-joint  is  given  by  Farabeuf  in  his  "  Precis  de  Manuel 
Operatoire,"  1885,  page  634. 

Comment. — 1.  Of  these  various  operations  those  by  the 
racket  method  may  be  considered  to  be  the  best. 

Of  the  two  methods  involved,  that  which  employs  the 
anterior  incision  appears  to  me  to  be  the  more  useful. 

AVith    no    other   form    of     disarticulating    at    the    hip- 


AMPUTATION  AT  THE  HIP- JOINT.  54S 

joint  have  I  experienced  siicli  good  results  as  with  this 
method. 

1.  The  External  Racket  method  has  the  following  points  to 
recommend  it : — 

(a)  The  elastic  tourniquet  can  be  applied. 

(6)  The  femur  is  approached  through  the  least  vascular 
part  of  the  limb,  and  disarticulation  may  be  effected  before  the 
main  mass  of  the  muscles  of  the  thigh  has  been  cut, 

(c)  The  vessels  of  the  part  are  divided  transversely,  and 
the  main  artery  is  severed  late  in  the  operation. 

(d)  Owing  to  the  low  position  of  the  incision  posteriorly, 
the  branches  of  the  gluteal  and  sciatic  artery  are  but  little 
interfered  with,  and  the  hiTemorrhage  from  these  vessels  is 
comparatively  trilling. 

(e)  The  muscles  are  divided  transversely,  and  the  wound- 
surface  therefore  is  small.  The  main  muscular  masses  are 
divided  low  dowTi,  so  that  in  a  sense  the  limb  is  removed  at  a 
point  further  from  the  trunk  than  obtains  in  some  of  the 
other  amputations,  and  shock  is  hereby  diminished. 

(/)  An  excellent  stump  is  provided — i.e.,  the  ischium  (the 
main  point  from  which  the  future  artificial  hmb  will  take  its 
support)  is  well  covered ;  the  cicatrix  is  brought  to  the  outer 
side  of  the  hmb,  and  is  as  far  removed  from  the  anus  as 
possible  ;  excellent  drainage  is  provided  for. 

(g)  The  position  of  the  vertical  incision  will  permit  of  the 
hip  being  explored  before  operation,  or  of  an  excision  being 
carried  out  should  it  be  revealed  that  amputation  is  not 
necessary. 

It  is  through  this  method  that  the  subperiosteal  operation 
can  be  best  carried  out. 

This  procedure  involves  a  considerable  expenditure  of  time, 
and  even  if  the  greatest  care  be  taken  it  is  scarcely  possible 
to  dissect  up  the  whole  of  the  periosteum  from  the  exposed 
part  of  the  femur. 

In  the  most  successful  cases,  as  in  Mr.  Shuter's  case  of  sub- 
periosteal amputation  (Clinical  Soc.  Trans.,  vol.  xvi.,  page  80), 
a  firm  resisting  cord  of  considerable  size  was  found  to  occupy 
the  centre  of  the  stump,  and  to  afford  a  common  point  of 
attachment  to  the  muscles. 

The  patient  was  able  to  move  the  stump  in  all  directions. 


544  OPERATIVE    SURGERY. 

and  to  communicate  those  movements  to  an  artificial  limb. 
There  is  no  evidence  that  any  new  bone  was  ever  reproduced 
in  the  stump. 

In  Mr.  Shuter's  case  the  patient  was  at  first  able  to  wear 
the  artificial  limb  for  some  hours  nearly  every  day ;  but 
subsequently  he  was  obliged  to  leave  it  off  on  account  of  its 
weight. 

In  Furneaux  Jordan's  operation  the  muscles  may  be 
divided  still  lower  down,  i.e.,  about  the  middle  of  the  thigli 
or  near  the  knee. 

Althousfh  the  circular  incision  is  made  low  do^m  in  the 
limb,  and  though  a  more  slender  segment  of  it  is  divided,  it 
must  be  remembered  that  the  deep  vertical  incision  required 
to  expose  and  resect  the  femur  is  proportionately  increased  in 
length.  Bleeding  from  this  vertical  wound  may  be  consider- 
able, since  several  of  the  perforating  arteries  are  cut. 

Shock  is  no  doubt  much  diminished  by  dividing  the  soft 
parts  low  down.  With  regard  to  the  long,  boneless  stump  left, 
Mr.  Jordan  writes : — "  If  the  thigh  were  to  remain  a  soft, 
pendulous  mass,  it  would  be  a  small  price  to  pay  for  greater 
safety ;  but  it  is  a  remarkable  circumstance  that,  as  a  rule,  the 
muscles  do  not  rest  until  the  longest  stump  has  become  a 
short  one." 

Esmarch's  method  has  the  advantage  of  being  rapid,  and 
is  moreover  easily  performed.  The  vessels  are  divided  and 
secured  at  an  early  stage  of  the  operation.  This  procedure 
is  well  adapted  for  the  apphcation  of  the  subperiosteal 
method. 

2.  The  disarticulation  through  an  anterior  racket  inci- 
sion has  many  of  the  advantages  of  the  previous  operation, 
and  has  other  special  claims  of  its  o^vn. 

(a)  All  forms  of  elastic  tourniquet  can  be  dispensed  with. 

(6)  The  muscles  are  divided  transversely,  and  the  wound- 
surface  is  comparatively  small. 

(c)  The  division  of  the  great  mass  of  the  muscles  is  made 
low  down. 

(d)  The  vessels  in  the  posterior  part  of  the  limb  are  but 
Httle  interfered  with. 

(e)  The  main  vessels  are  ligatured  early,  and  the  other 
arteries  are  secured  as  they  are  cut. 


AMPUTATION  AT  TEE  HIP-JOINT.  545 

(/)  The  hip-joint  is  directly  exposed,  and  disarticulation 
is  most  easily  effected. 

Compared  with  the  external  racket  method,  the  present 
procedure  has  those  possible  disadvantages  : — 

The  femur  is  exposed  through  a  muscular  and  vascular 
part  of  the  thigh,  and  the  vertical  incision  made  is  not  quite 
so  well  adapted  for  a  mere  exploratory  cut,  nor  for  an  excision 
wound  should  amputation  be  at  the  last  moment  abandoned. 

The  procedure  is  less  rapidly  effected,  although  the  actual 
disarticulation  is  easier.  This  depends  upon  the  fact  that 
the  smaller  divided  vessels  are  more  easily  dealt  with  after 
the  limb  has  been  removed  than  during  the  cutting  of  the 
flaps.  The  double  ligaturing  of  the  main  vessels  also  involves 
time. 

The  stump  is  good,  the  ischium  is  well  covered,  the  edges 
of  the  wound  come  easily  together,  but  the  flaps  are  not  quite 
so  well  adapted  to  favour  ready  drainage. 

3.  The  operation  by  antero-posterior  flaps  cut  by  trans- 
fixion has  the  advantage  of  great  rapidity  of  execution. 
Before  the  days  of  chloroform,  this  was  an  advantage  of  the 
primest  value. 

In  many  instances  at  the  present  time,  especially  in  cases 
of  amputation  for  injury,  rapidity  of  execution  is  of  very  con- 
siderable importance.  It  must  be  considered  to  what  extent 
this  single  great  advantage  can  overbalance  the  following 
grave  disadvantages  : — 

(a)  A  tourniquet  can  only  with  difficulty  be  applied. 

(6)  The  flaps  cannot  be  very  accurately  cut. 

(c)  The  muscles  are  divided  obliquely,  and  the  wound- 
surface  is  very  considerable. 

{d)  The  soft  parts  are  divided  high  up,  consequently  there 
should  be  greater  shock. 

(e)  The  branches  of  the  gluteal  and  sciatic  arteries  are 
so  freely  cut  that  copious  heemorrhage  from  the  posterior  flap 
is  common. 

(/)  The  stump  does  not  provide  a  very  excellent  covering 
for  the  ischium.  The  cicatrix  is  exposed  to  pressure ;  the 
wound  is  carried  very  near  to  the  anus,  and  efficient  drainage 
is  not  provided  imless  drainage-tubes  arc  employed. 

The  operation  has  advantages  in  military  surgery,  and  in 


5i6  OPERATIVE    SURGERY. 

some  cases  of  accident,  but  it  is  scarcely  applicable  to  dis- 
articulation for  disease. 

4.  Guthrie's  operation  is  strongly  recommended  by  several 
writers.  Ashhurst  ("  Encyclopaedia  of  Surgery  ")  considers  it 
to  be,  without  reserve,  the  best  mode  of  amputating  at  the 
hip-joint. 

The  operation  occupies  a  position  but  little  inferior  to  that 
held  by  the  external  and  anterior  racket  methods. 

The  same  advantages  can  be  claimed  for  it  as  are  claimed 
for  the  latter  operation.  The  muscles  are,  however,  not  di- 
vided so  transversely,  and  disarticulation  is  not  quite  so 
readily  effected.  The  operation  is,  on  the  other  hand,  more 
rapidly  performed,  and  the  femur  is  exposed  through  a  less 
fleshy  and  vascular  part  of  the  hmb. 

The  operation  is  inferior  to  the  external  racquet  method 
for  reasons  that  need  not  be  recapitulated. 

An  excellent  stump  results,  the  ischium  is  well  covered, 
the  wound  is  brought  more  to  the  outer  side  of  the  extremity, 
and  is  well  adapted  for  efficient  drainage.  The  cicatrix  is 
small  and  protected  from  pressure. 

AFTER-TREATMENT   OF   AMPUTATIONS   AT  THE   HIP-JOINT. 

After  the  operation  all  necessary  means  should  be  taken 
to  prevent  severe  shock.  The  head  should  be  kept  low,  the 
body  be  well  covered  with  blankets  and  kept  warm  by  hot 
bottles,  and,  if  necessary,  enemata  of  brandy  may  be  ad- 
ministered. 

By  means  of  a  suitable  cradle  the  stump  can  be  left  un- 
covered, and  the  dressings  be  exposed  to  the  air.  The  stump 
should  be  supported  upon  a  firm  pillow  or  cushion,  care 
being  taken  that  no  pressure  is  exercised  upon  the  wound. 

It  is  not  reasonable  to  suppose  that  the  great  wounds  left 
by  these  operations  will  heal  up  throughout  by  first  intention. 
There  is  always  a  considerable  disci large  of  soro-sanguinolent 
matter  from  the  large  wound-surface.  In  the  racquet  oper- 
ations, and  in  Guthrie's  disarticulation,  drainage  may  be 
secured  by  omitting  a  suture  or  so  at  the  most  depend- 
ent point  of  the  wovmd.  In  the  transfixion  operation  by 
antero-posterior  flaps,  a  drainage-tube  will  most  probably  be 
required. 


AMPUTATION  AT   THE  HIP-JOINT.  547 

The  weight  of  the  flaps  renders  it  important  that  the 
sutures  should  not  be  removed  too  soon,  and  after  their  re- 
moval it  will,  as  a  rule,  be  found  necessary  to  support  the 
flaps  by  strapping. 

Care  must  be  taken  that  the  dressings  are  not  soiled 
by  urine  or  faeces,  and  that  bed-sores  do  not  form  over  the 
sacrum  or  the  trochanter  of  the  opposite  side. 


549 


tSart  VI. 

OPERATIONS   ON   THE  BONES  AND 
JOINTS. 

CHAPTER     I. 
Osteotomy. 

By  osteotomy  is  understood  the  division  of  a  bone  in  its 
continuity  for  the  rehef  of  deformities  of  various  kinds. 

The  operation  has  been  adopted  in  the  treatment  of  such 
conditions  as  the  deformity  produced  by  mal-union  after 
fracture,  the  curving  of  bones  incident  to  rickets  or  extensive 
necrosis,  osseous  anchylosis  of  jomts,  genu  valgum,  and  some 
other  deviations. 

Linear  osteotomiy  impHes  the  division  of  the  bone  in  its 
continuity  in  a  single  transverse  hue,  the  subcutaneous 
method  being  carried  out. 

Cuneifomi  osteotomy  is  the  term  applied  to  the  cuttmg- 
out  of  a  wedge-shaped  piece  for  the  rehef  of  such  deformity 
as  that  represented  by  the  curved  tibia  met  with  in  rickets. 

In  both  forms  the  operation  may  be  performed  by  means 
of  a  saw,  or  a  chisel,  or  an  osteotome. 

The  earher  operations  were  performed  for  the  relief  of 
deformity  following  upon  fracture,  and  the  bone  was  divided 
through  a  large  open  wound. 

Thus  Lemercier,  in  1815,  sawed  throuo'h  the  femur  to 
correct  the  deformity  due  to  mal-union  of  a  fracture  of  tiiat 
bone. 

The  first  osteotomy,  in  the  sense  in  which  the  term  is  now 
usually  employed,  was  performed  by  Rhea  Barton,  an  Ameri- 
can surgeon,  in  1826  {North  American  Medical  and  Sv/r- 
gical  Journal,  April,  1827).      He  divided  the  femur  between 


550  OPERATIVE    SURGERY. 

the  two  trochanters,  to  remedy  a  vicious  anchylosis  of  the 
hip-joint.  A  saw  was  used,  and  a  large  skin -incision  made. 
The  osteotomy  was  Unear. 

Another  American  surgeon — Rodgers — is  credited  with 
having  performed  the  first  cuneiform  osteotomy  in  1880  (also 
for  anchylosis  at  the  hip). 

A.  Key  performed  in  England  a  linear  osteotomy — with  a 
saw — for  the  treatment  of  an  angular  bend  in  the  tibia  follow- 
ing fracture  (Guy's  Hospital  Reports,  183P,  page  193). 

Langenbeck  carried  out  the  first  subcutaneous  osteotomy 
in  1852-3  (Deutsche  Klinik,  1854,  No.  30). 

Meyer,  of  Wiirzburg,  appears  to  have  performed  the  first 
osteotomy  for  rickety  curvatures  in  1851  (Illustrirte 
Medizin.  Zeit,  1852,  pages  1  and  65). 

Mr.  Stromeyer  Little  claims  to  have  performed  the  first 
subcutaneous  osteotomy  in  England  in  1868  ("In-Knee 
Distortion,"  1882,  page  149).  The  case  was  one  of  osseous 
union  of  the  knee-joint.     A  chisel  and  mallet  were  employed. 

Adams'  operation  upon  the  neck  of  the  femur  for  bony 
anchylosis  dates  from  1869  ("A  New  Operation  for  Bony 
Anchylosis  of  the  Hip-joint,"  1871).  Ogston's  operation  for 
genu  valgum  dates  from  May,  1876  (Edinburgh  Medical 
Journal,  March,  1877),  and  Mace  wen's  osteotomy  for  that 
deformity  was  first  carried  out  in  1877  (Lancet,  March, 
1877). 

The  Instruments  employed. 

The  following  are  the  instruments  required  in  these 
operations : — (1)  An  ordinary  scalpel ;  (2)  chisels  and  osteo- 
tomes of  various  sizes ;  (3)  mallet ;  (4)  saws  for  subcutaneous 
division  of  bones  ;  (5)  sand  bag ;  (6)  blunt  hooks. 

The  Chisels  and  Osteotomes  employed  are  those  introduced 
by  Dr.  Macewen.  The  chisel  has  the  same  form  as  the 
ordinary  carpenter's  chisel.  It  is  square  at  the  end,  and  has 
a  very  sharp  edge.  It  should  be  made  of  the  finest  steel, 
and  be  very  carefully  tempered.  The  part  of  the  instrument 
near  the  cutting  edge  is  alone  raised  to  a  great  degree  of 
hardness  ;  the  rest  of  the  blade  is  kept  softer,  so  that  there 
shall  be  no  danger  of  its  snapping.  The  edge  is  bevelled  on 
r)ne  side  only,  according  to  the  ordinary  pattern,  and  the 
thickness  of  the  blade  at  the  base  of  the  bevel  is  about  one- 


OSTEOTOMY.  551 

twelfth  of  an  inch  (Fig.  150).  Chisels  with  unduly  thick 
blades  are  clumsy,  and  are  apt  to  splinter  the  bone. 

It  is  desirable  that  the  blade  and  the  handle  be  made  of 
one  piece  of  metal :  that  the  handle  be  octagonal,  for  con- 
venience of  holding  ;  and  that  the  head  be 
rounded,  smooth,  and  projecting,  to  receive 
the  blows  of  the  mallet  (Fig.  151). 

Macewen's  osteotome  has  a  wedge- 
shaped  extremity,  and  has  the  outline,  as 
seen  sideways,  of  an  attenuated  double- 
inclined  plane  (Figs.  150  and  151).  It  is 
square  at  the  end,  has  a  sharp  edge,  and  is 
tempered  in  the  same  way  as  the  chisel. 
The    precise    fashioning    of    the    blade    is  p-     j^^^ 

shown  in  the  full-sized  figure  (Fig.  150).  section  of  section 
The  handle  and  the  extremity  '  of  the  '^'''''''-  ?'e°o^ 
instrument   are    the    same    as    the    chisel.       ,^  ^,      ^      tome. 

.  ■,..,■■  (Botli  natural  size.) 

Indeed,  these  two   instruments  difter  only 

in  the  manner  in  which  their  cutting  extremities  are  bevelled. 

They  should  present  various  widths  of  blade,  according  to 
the  size  of  the  bone  to  be  divided.  The  most  convenient 
sizes  are  represented  by  three  instruments,  the  smallest  of 
which  is  one-third  of  an  inch  wide  in  the  blade  and  the 
largest  from  half  an  inch  to  two-thirds  of  an  inch  in  width. 
Upon  the  side  of  the  osteotome  a  half-inch  scale  is  marked, 
so  that  the  depth  to  which  the  instrument  has  passed  may  be 
noted. 

The  chisel  is  used  only  for  paring,  shaving,  and  cutting 
out  wedges  of  bone,  as  in  cuneiform  osteotomy. 

The  osteotome  is  employed  only  for  making  simple  in- 
cisions or  wedge-shaped  openings,  but  without  removal  of 
bone.  The  chisel,  like  the  ordinary  carpenter's  chisel,  is  apt 
to  go  awry  if  a  straight  section  be  attempted. 

It  is  well  that  new  instruments  should  be  tried  upon  the 
bones  of  animals  before  being  used  in  operating  upon  the 
living  subject,  if  there  be  any  doubt  as  to  their  strength. 

In  one  ca^e,  when  dividing  the  femur  for  deformity  fol- 
lowing a  mal-united  fracture,  I  was  horrified  to  find  on  re- 
moving  the  osteotome  that  a  large  angular  piece  had  been 
broken  from  the  cutting  edge.     I  was  unable  to  remove  the 


552 


OPERATIVE    SUKGEBT. 


fragment,  but  the  bone  united  without  comphcation,  and  no 
inconvenience  followed  upon  the  retention  of  the  piece  of 
steel,  which  was  no  doubt  buried  in  the  callus. 

The  Mallet  is  made  of  some  hard  Avood,  such  as  lignum 
vitce.  The  leaden  mallets  used  by  many 
French  surgeons  have  little  to  recom- 
mend them. 

The  Saws  used  for  the  subcutaneous 
division  of  bone  are  founded  upon  Adams' 
saw.  The  blade  is  very  slender,  and 
the  serrated  edge  is  of  hmited  extent 
(Fig.  152).  Many  saws  have  been  intro- 
duced, but  they  differ  httle  fi-om  Adams' 
instrument,  except  in  the  shape  of  the 
handle  or  in  the  mclination  of  the  blade 
to  the  handle.  Trocar  saws  and  con- 
cealed saws  are  ingenious,  but  are  of  no 
especial  practical  value. 

The  Sand  Bag  or  Sand  Pilloiv  is  used 
for  the  purpose  of  fixing  or  imbedding  the 
hmb  during  the  process  of  dividing  the 
bone  with  the  osteotome. 

The  sand  pillow  used  by  Dr.  Macewen 
measures  18  inches  by  12  inches.  The 
case  is  filled  with  sand  just  sufficient  to  enable  it  to  be 
shifted  from  one  part  of  the  bag  to  another  without  leaving 
an}^  portion  empty — a  moderate  fulness  without  distension, 
"The  sand  is  moistened  just  before  the  operation,  to  prevent 
the  escape  of  dust  and  to  produce  gi-eater  cohesion  betAveen 
its  particles,  so  that  it  will  more  readily  retain  the  form  or 
mould  imparted  to  it.  It  is  then  covered  with  a  sheet  of 
jaiconet  or  other  waterproof  material,  and  laid  on  a  table" 
(^Macewen). 


Fig.   151. — siacewen's 

OSTEOTOilE. 


THE    OPERATION. 


1.  Linear  Osteotomy  with  the  Osteotome. 

The  operation  cannot  be  better  described  than  in  the 
terms  employed  by  its  author,  Dr.  Macewen : — 

"  The  patient  ought  to  be  placed  fully  under  the  influence 
of  an  anijesthetic,  and  this  should  be  maintained  during  the 


OSTEOTOMY.  553 

performance  of  the  operation  and  until  the  Hmb  is  securely 
fixed  in  splints.  After  the  patient  is  fully  anaesthetised,  the 
limb  is  rendered  bloodless  .  .  .  and  is  placed  on  a  sand 
pillow.  .  ,  .  The  hmb  is  then  imbedded  in  the  pillow  in 
the  manner  suitable  for  the  particular  operation. 

"  In  order  to  introduce  either  the  saw  or  the  osteotome,  a 
wound  in  the  soft  parts  must  be  made.  This  wound  ought  to 
be  a  sharp,  clean,  single  incision,  produced  by  one  stroke  of 
the  instrument  whenever  this  is  practicable.  Dissection  ought 
to  be  avoided,  the  situation  in  which  the  incision  is  to  be 
made  being  chosen  so  as  to  get  to  the  bone  as  directly  as 
possible.  The  direction  of  the  incision  should  be  in  a  line 
with  that  of  the  muscular  fibres  about  to  be  penetrated.  The 
situation  of  the  wound  in  the  soft  parts  ought  to  be  selected 


Fig.    152. — ADAMS'    SAW. 

so  as  to  avoid  cutting,  not  only  the  larger  vessels,  but  also 
the  smaller  ones,  when  this  can  be  done. 

"  As  to  the  extent  of  the  incision,  this  depends  greatly 
on  the  surgeon,  whether  he  wishes  to  see  what  he  is  doing, 
or  whether  he  can  trust  to  the  tactile  sensations  conveyed 
through  the  instrument  to  his  hand  as  a  sufficient  guide.  If 
the  latter,  the  wound  need  only  be  large  enough  to  admit  the 
osteotome  ;  if  the  former,  it  would  require  to  be  a  couple  or 
more  inches  in  length,  according  to  the  depth  of  the  tissues. 
When  a  surgeon  commences  to  practise  osteotomy,  it  would 
be  well  for  him  to  make  a  large  incision,  one  sufficient  to 
enable  him  to  examine  the  bone  with  the  finger,  or  even  to 
see  the  bene.  In  this  way  he  performs  his  operation  Avith 
more  confidence,  and  the  extent  of  his  incision  is  an  element 
of  safety,  inasmuch  as  it  provides  a  ready  exit  for  discharge — 
blood  or  serum — which  otherwise  might  be  pent  up  in  the 
parts,  causing  distension.  After  he  has  gained  a  httle  more 
experience,  the  osteotome  may  be  used  as  a  probe  (the  saw 


654  OPERATIVE    SURGERY. 

will  never  answer  this  purpose),  the  sensations  conveyed 
through  the  instrument  being  sufficient  to  enable  the 
operator  to  ascertain  all  that  can  be  known  by  the  intro- 
duction of  the  finger.  When  the  operator  has  reached  this 
stage,  all  that  is  necessary  is  to  make  an  incision  which  will 
enable  the  osteotome  to  reach  the  bone — from  half  an  inch  to 
an  inch  long,  according  to  the  breadth  of  the  blade.  By 
operating  in  this  way  the  tissues  are  much  less  disturbed, 
there  is  less  effusion  of  blood  or  serum,  and  much  less  need  of 
drainage. 

"  When  small  wounds  are  made,  the  knife  ought  to  remain 
in  situ  until  the  saw  or  the  osteotome  is  introduced  by  the 
side  of  it  to  the  bone,  the  knife  acting  as  a  guide.  When  the 
osteotome  has  reached  the  bone,  it  should  be  turned  in  tlie 
du'ection  in  which  the  osseous  incision  is  to  be  made,  care 
being  taken  while  doing  this  not  to  denude  the  bone  of 
periosteum. 

•'  The  osteotome  ought  to  be  used  in  such  a  way  as  to 
direct  its  cutting  edge  away  from  any  important  soft  struc- 
tures which  it  may  be  necessary  to  avoid.  As  the  osteotome 
has  blunt  sides,  it  may  be  used  to  lever  the  soft  tissues  aside, 
keeping,  meanwhile,  the  cutting  edge  of  the  instrument  in 
close  contact  with  the  bone. 

"  After  a  little  practice,  the  osteotome  acts  as  a  probe,  and 
when  once  the  tactile  impressions  conveyed  through  the 
instrument  are  cultivated,  it  becomes  a  delicate  indicator  of 
the  state  of  the  bone,  the  precise  relation  of  the  osteotome  to 
it,  and  the  extent  of  the  osseous  incision.  But  when  the 
osteotome  has  been  imbedded  in  the  bone  for  an  inch  or  two, 
its  delicacy  of  touch  is  lost,  and  it  no  longer  remains  a  pre- 
cise indicator  of  what  is  in  contact  with  its  cutting  edge. 
This  is  due  to  the  manner  in  which  the  sides  of  the  instru- 
ment are  pressed  on  and  caught  by  the  bone,  the  amount  of 
lateral  pressure  varying  according  to  the  amount  of  the 
osseous  tissue  through  which  the  instrument  passes. 

"  This  may  be  easily  rectified  by  introducing  a  finer  instru- 
ment by  the  side  of  the  thicker  one  first  used,  and  with- 
drawing the  latter.  The  finer  instrument  is  then  placed  in 
the  osseous  groove  made  by  the  thick  one  ;  but,  being  a  more 
attenuated  wedge,  its  sides  are  not  pressed  on,  so  that  it  acts 


OSTEOTOMY.  555 

as  an  indicator  of  the  kind  of  tissue  in  immediate  contact 
with  its  cutting  edge.  This  can  be  repeated  in  a  thick 
bone  by  the  substitution  of  a  third  instrument  of  still 
greater  acuteness. 

"  When  using  the  osteotome,  it  ought  to  be  grasped  firmly 
in  the  left  hand,  steadied  by  the  inner  border  resting  on  the 
patient's  limb.  The  surgeon  ought  to  cut  to,  instead  of  from, 
himself ;  thus,  if  the  surgeon  is  operating  on  the  inner  side  of 
the  left  limb,  he  ought  to  stand  on  the  left  side  of  the  patient, 
and  cut  towards  himself 

"If  the  suro-eon,  instead  of  following  this  instruction, 
should  hold  the  osteotome  loosely,  a  slightly  uneven  l)lovv 
with  the  mallet  would  outweigh  his  grip,  and  might  cause  the 
instrument  to  sUde  along  the  surface  of  the  bone,  peeling  the 
periosteum,  or  causing  a  more  unpleasant  accident,  such  as 
penetration  of  an  artery. 

"  When  the  chisel  is  placed  in  position,  the  mallet  may 
then  be  brought  into  requisition,  being  used  by  the  right  hand. 
When  the  external  shell  of  bone  is  felt  to  have  given  way,, 
it  is  not  advisable  to  attempt  to  complete  at  once  this 
particular  portion  of  the  section,  because  the  instrument  is 
apt  to  be  caught.  In  order  to  avoid  the  impaction,  the  entire 
superficial  portion  of  the  section  ought  to  be  completed  in 
the  first  instance,  so  as  to  permit  a  little  movement  of  the 
instrument  in  the  direction  of  its  breadth ;  and  by  making  a 
series  of  such  movements,  after  each  impulse  given  by  the 
mallet,  there  can  be  no  fixity.  The  osteotome  ought  not  to 
be  pressed  against  the  bone  transversely  to  its  breadth,  as  it 
is  possible  that  it  may  be  broken  or  twisted  by  so  doing.  The 
bone  itself  may  be  splintered  longitudinally  by  such  pressure. 
In  no  instance  should  the  osteotome  or  chisel  have  a  breadth 
greater  than  the  diameter  of  the  bone  about  to  be  cut,  other- 
wise the  soft  structures  at  either  side  are  apt  to  be  injured." 
(See  also  the  account  of  Macewen's  operation  for  genu  valgum, 
page  567.) 

Com'nient — This  operation  should  never  be  attempted 
until  the  surgeon  has  gained  quite  an  extensive  experience 
by  operating  upon  animals'  bones,  which  should  be  quite 
fresh,  and  be  imbedded  upon  a  sand-bag,  and  by  perform- 
ing osteotomies  upon   the   cadaver.      The  manual   dexterity 


556  OFERATIVE    SUEGEBY. 

required  is  of  a  special  kind,  and  can  onl}^  be  developed  by 
practice.  The  osteotome  and  mallet  are  powerful  instru- 
ments, which  demand  the  greatest  precision  and  nicety  in 
their  handling,  and  which  become  most  dangerous  imple- 
ments when  employed  by  those  who  have  taken  no  trouble 
to  acquu-e  famiharity  with  their  use. 

After  such  a  series  of  experiments  as  has  been  named,  the 
operator  can  divide  a  bone  with  neatness  and  accuracy ;  he 
has  learnt  precisely  what  amount  of  force  to  use  and  how  to 
use  it,  and  he  can  follow  the  progress  of  the  buried  chisel  as 
easily  as  if  the  instrument  and  the  bone  were  beneath  his 
eye. 

There  should  be  no  need,  therefore,  to  make  a  larger 
incision  in  the  soft  parts  than  is  required  for  the  mere 
introduction  of  the  osteotome  or  chisel,  and  a  surgeon  would 
do  Avell  not  to  operate  upon  the  Hving  subject  until,  by 
careful  practice,  he  has  acquired  confidence  in  himself  and 
in  his  abihty  to  operate  through  a  small  incision. 

In  my  opinion  no  tourniquet  or  elastic  band  should  be 
employed  to  render  the  limb  bloodless.  While  Esmarch's 
elastic  compressor  obviously  prevents  any  bleeding  during  the 
actual  operation,  it  is  certain  that  it  induces  a  greater  degree 
of  oozing  when  the  bandage  is  removed  (page  279).  There 
is  no  operation  area  to  be  obscured  by  blood.  The  surgeon 
guides  his  instrument  by  his  touch  and  not  by  his  eyes.  If 
an  artery  should  be  divided  by  accident,  the  sooner  the  injury 
is  discovered  the  better.  The  Esmarch's  band  merely  ]^)nst- 
pones  the  discovery  until  a  larger  and  deeper  wound  lias 
])robably  been  made,  and  is  of  no  assistance  in  lessening  the 
severity  of  the  lesion. 

Other  things  being  equal,  I  should  say  that  in  osteotomy 
more  blood  wiU  be  lost  by  the  "  bloodless  method  "  than  by 
an  operation  carried  out  in  a  limb  the  circulation  of  which 
has  been  in  no  way  restrained. 

It  should  be  a  rule  that  the  incision  in  the  soft  parts 
should  be  so  placed  as  to  reach  the  bone  by  the  shortest  and 
safest  route  and  in  the  most  convenient  place,  and  it  shoukl 
be  in.  a  line  with  the  section  it  is  proposed  to  make  in  the 
bone.  Dr.  Macewcn  makes  the  incision  in  the  soft  parts  at 
right  angles   to  the   line  of  the  incision   on  the  bone,  and 


OSTEOTOMY.  557 

introducing  the  osteotome,  turns  it  into  place  after  introduc- 
tion. This  comphcatcs  matters  a  httle,  and  although  it  is  quite 
in  accord  with  the  principles  of  the  subcutaneous  method, 
the  measure  is — with  modern  antiseptic  precautions — un- 
necessary. 

The  osteotome  should,  of  course,  always  be  so  applied  as 
to  cut  from  and  not  towards  the  main  artery,  should  it  be 
near  the  line  of  section.  In  one  or  two  positions  this  is  not 
quite  possible,  e.g.,  so  far  as  concerns  the  upper  tuberosity  of 
the  tibia  and  the  popliteal  artery. 

When  once  the  osteotome  has  cut  into  the  bone,  care 
should  be  taken  that  the  cut  be  not  lost.  If  the  blade  shp 
or  be  removed,  much  time  may  be  wasted  and  no  little 
damage  done  in  attempting  to  find  again  the  original  cleft  in 
the  bone. 

2.  Linear  Osteotomy  with  the  Saw. 

This  operation  differs  but  little  from  the  last,  except  in 
the  main  element  that  the  saw  is  used  in  the  place  of  the  chisel. 

The  same  care  is  taken  that  the  procedure  is  sub- 
cutaneous, and  that  as  httle  damage  as  possible  is  done  ta 
the  soft  parts. 

The  best  situation  for  dividing  the  bone  having  been 
selected,  and  the  part  being  firmly  held,  a  narrow-bladed 
knife  is  passed  through  the  skin  down  to  the  bone.  The 
tissues  are  so  divided  that  the  bone  is  laid  bare  along  the  line 
wliich  the  saw  must  travel.  The  knife  employed  should  be 
shaped  like  a  tenotome,  must  be  long  enough  to  cover  the 
whole  distance  in  the  case  of  a  deej)-seated  bone,  and  the 
cutting  edge  should  not  extend  along  the  whole  length  of  the 
blade.  While  the  knife  is  being  manipulated  in  the  depths 
of  the  limb,  the  non-cutting  part  of  the  blade  should  then 
be  in  contact  with  the  skin.  The  knife  is  employed  to  make 
a  space  for  the  passage  of  the  saw,  and  the  deep  incision 
should  not  be  so  incomplete  that  the  saw  has  to  be  forced 
through  the  tissues.  The  skin  wound  should  be  as  smaU 
as  possible,  and  should  be  made  at  right  angles  to  the  surface 
to  be  sawn. 

Before  the  tenotome  is  quite  withdrawn  the  saw  should 
be  carefully  introduced  by  the  side  of  it,  so  as  to  reach  the 
part  of  the  bone  which  has  been  incised.     When  the  saw  is 


558  OPERATIVE    SURGE  BY. 

in  position,  the  knife  is  withdrawn.  A  suitable  pattern  of  the 
Adams'  saw  is  employed. 

The  saw  must  be  used  with  short  strokes,  and  care  must 
be  taken  that  its  tip  is  not  ruthlessly  thrust  into  the  tissues 
upon  the  opposite  side  of  the  bone. 

Especial  care  should  be  taken  to  see  that  the  saw  is  per- 
fectly clean,  and  that  the  composition  with  which  it  has  been 
brightened  has  been  brushed  out  from  among  the  teeth. 

Comparison  of  the  Two  Methods. 

Of  these  two  methods,  that  of  dividing  the  bone  by  means 
of  an  osteotome  is  undoubtedly  the  better.  The  saw  is  easier 
to  use,  and  carries  with  it  the  comparative  safety  which 
belongs  to  a  blunt  instrument.  Its  use,  however,  leaves  a 
quantity  of  bone  debris  in.  the  depths  of  the  wound,  which, 
while  it  often  appears  to  be  harmless,  may  yet  act  as  irritant 
foreign  matter  and  excite  suppuration.  There  is  considerable 
risk  of  lacerating  the  soft  parts  around  the  bone  with  the  tip 
of  the  saw,  and  also  with  its  blade  as  the  section  is  being 
completed.  As  Dr.  Macewen  points  out,  the  pump-like 
movement  of  the  saw  is  apt  to  introduce  air  into  the  wound, 
and  to  do  away  with  the  subcutaneous  principle. 

The  osteotome,  or  chisel,  on  the  other  hand,  is  somewhat 
difficult  to  use,  and  while  perfectly  safe  in  the  hands  of  an 
experienced  operator,  is  a  dangerous  weapon  when  used  by  a 
bep-inner.  The  parts  are  divided  by  a  clean,  fine,  simple  cut. 
The  instrument  is  not  moved  to  and  fro  in  the  hne  of  the 
wound.  There  is  no  bone  debris,  and  there  should  be  no 
laceration  of  soft  parts.  The  instrument  is  powerful  and  of 
wide  application. 

8.  Cuneiform  Osteotomy. 

In  this  form  of  the  operation  a  cuneiform  or  wedge- 
shaped  piece  of  bone  is  removed  to  remedy  an  abnormal  curve 
or  angular  deformity.  It  has  been  applied  in  the  treatment 
of  the  curved  femora  and  tibiae  resulting  from  rickets,  in 
some  cases  of  bony  anchylosis  at  an  unusual  angle,  and  in  a 
few  examples  of  angular  deformity  produced  by  mal-union 
after  fracture. 

The  exact  size  and  shape  of  the  wedge  must  be  carefully 
determined,  and  must  obviously  depend  upon  the  position  and 
extent  of  the  deformity. 


OSTEOTOMY. 


559 


\ 

Fig.  ISS. — DIAGRAM  TO  SHQ-W  THE  LINES  OF  THE 
CHISEL  CUTS  IN  CTJNEIFOEM  OSTEOTOMY  FOE 
ANGULAR  DEFORMITY  AFTER   FRACTURE,    ETC. 


In  general  terms,  it  may  be  said  that  tlie  sides  of  the 
wedge  should  be  at  right  angles  to  the  axis  of  the  bone 
respectively  above  and  below  the  seat  of  the  operation 
(Figs.  153  and  160).  In  actual  practice,  however,  so  large  a 
wetlge-shaped  piece  of  bone  is  very  seldom  removed.  If  the 
curvature  in  the  bone 
be  not  extreme  many 
surgeons  content 

themselves  with  a 
mere  linear  osteotomy, 
leaving  a  gap  between 
the  divided  ends  when 
the  limb  has  been 
adjusted,  which  gap 
appears  to  fill  up 
"without  complication 
(Fig.  159,  c). 

In      the      severer 
kinds  of  deformity  a  wedge  may  be  removed  much  smaller 
than  is  necessary  to  entirely  overcome  the   deviation,  a  gap 
of  moderate  size  being  left  when  the  limb  has  been  brought 
into  its  normal  position  upon  a  splint. 

The  wedge,  moreover,  need  not  extend  through  the  entire 
thickness  of  the  bone.  It  may  involve  possibly  three-fourths 
of  the  diameter  of  the  bone,  the  remaining  fourth  being  bent 
or  broken. 

In  performing  this  operation  a  chisel  will  be  found  in 
most  instances  to  be  more  convenient  than  a  saw. 

In  some  forms  of  bony  anchylosis  of  joints,  however,  the 
saAv  may  prove  to  be  the  more  suitable  instrument,  or  both 
saw  and  chisel  may  be  used  together. 

The  incision  in  the  soft  parts  must  of  necessit}^  be  com- 
paratively large — as  large  at  least  as  the  base  of  the  intended 
wedge.  It  need  be  no  larger,  since  the  skin  can  be  displaced 
in  one  or  other  direction  according  to  the  position  of  the 
chisel. 

As  soon  as  the  bone  is  exposed,  the  periosteum  must  be 
divided  and  carefully  separated  with  the  elevator. 

In  dividing  the  bone  the  chisel  shoidd  be  employed  and 
not  the  osteotome. 


560  OPERATIVE    SUBGEIiF. 

The  instrument  must  be  so  held  that  the  straight  eds^e  is 
towards  the  bone  to  the  left,  and  the  bevelled  edg^e  towards 
the  portion  to  be  removed. 

If  a  large  wedge  has  to  be  removed,  it  should  be  dealt 
with  in  sections.  A  small  wedge-shaped  piece  should  first  be 
taken  out,  and  then  thin  slices  of  bone  should  be  shaved  from 
each  side  of  the  exposed  bone  until  a  cuneiform  cavity  of  the 
desired  size  and  shape  has  been  produced. 

If  an  attempt  be  made  to  remove  a  large  wedge  at  once,  it 
will  be  found  that  the  chisel  is  apt  to  go  a>viy,  to  incline 
towards  the  straight  edge,  and  in  consequence  an  uncertain 
division  of  the  bony  tissue  is  made. 

There  is  apt  to  be  free  oozing  as  the  cancellous  tissue  is 
being  cut  through. 

It  is  not  w^eU  to  attempt  to  prise  out  the  wedge  of  bone 
with  the  chisel.  The  bone  so  treated  is  apt  to  spHt,  or  tht^ 
chisel  may  be  broken.  The  w^edge  can  be  removed  better 
with  forceps  aided  by  an  elevator. 

After  the  bone  has  been  dealt  with,  the  periosteal  flaps 
may  be  brought  together  by  a  few  fine  catgut  sutures.  The 
sldn  wound  should  not  be  too  completely  closed,  but  room 
left  for  drainage. 

A  sponge  dusted  with  iodoform,  or  a  pad  of  Tillmann's 
dressing,  forms  the  best  dressing. 

No  especial  observations  need  be  added  with  reference  to 
cuneiform  osteotomy  performed  with  the  saw. 

The  After-treatment. — The  after-treatment  of  osteotomy 
cases  is  very  simple.  The  case  is  one  of  compound  fracture 
made  in  the  most  favourable  circumstances. 

The  limb  must  be  put  up  in  a  suitable  splint  which  will 
correct  the  deformity,  keep  the  divided  ends  of  the  bones  in 
close  apposition,  and  maintain  the  limb  at  absolute  rest.  As 
many  of  the  patients  are  children,  the  selection  of  a  proper 
splint  is  a  matter  of  moment. 

The  time  during  which  the  limb  must  be  kept  adjusted 
upon  the  splint  will  correspond  to  the  time  required  for  a 
fracture  of  the  same  bone  to  consolidate.  Indeed,  the  after- 
treatment  is  essentially  that  observed  in  cases  of  fracture. 

In  the  majority  of  instances  no  sutures  are  needed  for  the 
wound.     They  should  be  avoided  whenever  possible. 


OSTHJUTOMY.  561 

I  have  always  dressed  my  osteotomy  wounds  with  a  large 
clean  sponf^e  well  dusted  with  iodoform.  This  sponge  is 
bandaged  firmly  over  the  wound  with  a  flannel  bandage.  In 
the  majority  of  cases  this  very  simple  dressing  need  not  be 
removed  until  some  weeks  have  elapsed  and  the  union  of  the 
bone  is  advanced. 

Results. — The  results  of  osteotomy  operations  may  be 
said  to  be  in  every  way  excellent.  Since  the  introduction  of 
the  subcutaneous  method,  since  the  methods  of  operating 
have  been  more  precise,  and  since  the  employment  of 
antiseptic  measures  in  the  treatment  of  the  wound  has  been 
introduced,  the  risk  attending  these  operations  has  been 
reduced  to  an  insignificant  figure.  Indeed,  the  commoner 
osteotomies  may  be  said  to  be  practically  devoid  of  risk.  Dr. 
Macewen  alone  has  published  a  series  of  330  cases  operated 
on  for  various  deformities  of  the  lower  limbs,  and  among  this 
number  there  was  no  death  as  a  result  of  the  bone  section. 


662 


CHAPTER   II. 

Osteotomy  for  Faulty  Anchylosis  of  the  Hip-Joint. 

This  measure  is  carried  out  in  certain  cases  of  rigid  an- 
chylosis of  the  hip-joint,  resulting  from  disease,  in  -which 
the  limb  has  assumed  a  faulty  position,  and  all  milder  methods 
of  treatment  have  failed.  In  the  most  usual  deformity  the 
thigh  is  flexed,  adducted,  and  a  Httle  rotated  in.  The  object 
of  the  operation  is  to  bring  the  limb  straight.  The  possibility 
of  securing  a  movable  joint  at  the  same  time  may  or  may 
not  be  contemplated  by  the  operator. 

A.  Through  the  Neck  of  the  Femur. 

This  operation  may  be  performed  either  with  the  saw  or 
with  the  osteotome. 

Operation. — 1.  With  the  Saw  (Adams'  Operation). — This 
procedure  is  thus  described  by  Mr.  W.  Adams : — 

"  The  left  thumb  is  placed  firmly,  so  as  to  compress  the  soft 
tissues  sohdly  against  the  bone,  at  a  point  situated  at  the 
centre  of  the  top  of  the  great  trochanter  and  the  breadth  of 
one  finger  above  it. 

"  At  this  point  the  narrow-bladed  knife  is  pushed  in  till  it 
reaches  the  neck  of  the  femur,  at  a  right  angle  across  the 
front  of  which  it  is  then  carried  (Fig.  154,  a).  The  knife  is 
then  gently  moved  to  cut  a  space  for  the  easy  insertion  of  the 
saw,  which,  traversing  the  course  of  the  knife,  reaches  the 
front  of  the  neck  of  the  femur,  and  gradually  cuts  it  com- 
pletely through.  The  surgeon  cuts  until  he  feels  that  the 
saw  is  free  of  the  bone,  and  movmg  in  the  soft  tissues  only 
behind  the  bone." 

2.  With  the  Osteotome. — The  patient  lies  upon  the  sound 
hip,  and  the  surgeon  stands  to  the  outer  side  of  the  limb. 
An  assistant  steadies  the  thigh  and  pelvis. 

A  longitudinal  incision  about  three^fourths  of  an  inch  in 
length  is  made  just  above  the  great  trochanter,  and  in  the 


OSTEOTOMY  OF  THE  FEMUlt. 


563 


axis  of  the  neck  of  the  bone.  The  knife  is  carried  well 
down  to  the  bone.  The  osteotome  follows  the  knife,  and  on 
reaching  the  femur  is  turned  on  its  axis  so  that  its  cutting 
edge  is  at  right  angles  to  the  axis  of  the  neck. 

A  few  blows  from  the  mallet  will  suffice  to  divide  the 
bone. 

B.  Through  the  Shaft  of  the  Femur  below  the  Tro- 
chanters. 

The  operation  most  usually  carried  out  in  this  situation  is 
that  known  as  Gant's.  Mr.  Gant  per- 
formed the  operation  in  1872  (Lancet, 
Dec,  1872).  Either  the  saw  or  the  os- 
teotome may  be  employed.  The  latter 
should  be  the  instrument  selected. 

Operation.  —  The  osteotomy  is 
carried  out  precisely  as  in  the  pro- 
cedure just  described. 

The  incision  is  longitudinal,  is 
placed  over  the  outer  aspect  of  the 
femur  and  about  at  the  level  of  the 
lesser  trochanter. 

The  osteotome  is  introduced,  is 
turned  upon  its  axis  in  the  manner 
already  described,  and  the  bone  is 
divided  immediately  below  the  lesser  tro- 
chanter and  in  a  line  at  right  angles  to 
the  shaft  of  the  femur  (Fig.  154,  b). 

Comment. — In  these  situations  the  bone  should  be  divided 
completely.  It  should  not  be  partially  cut  through  and  then 
fractured,  lest  dangerous  splinters  of  bone  be  produced. 
The  assistant  therefore  should  be  carefid  how  he  holds  the 
limb,  and  how  he  brings  pressure  to  bear  upon  the  parts 
which  are  being  divided. 

Splinters  of  bone  resulting  from  section  of  the  neck  of 
the  femur  have  been  driven  into  adjacent  arteries,  and  serious 
bleeding  has  resulted  ( Jacobson's  "  Operations  of  Surgery," 
page  1388). 

As  to  the  instrument  to  be  used,  reasons  have  been  already 
given  (page  558)  for  preferring  the  osteotome  to  the  saw,  and  to 
operations  in  this  region  the  same  criticisms  apply. 


Fig.  154.— OSTEOTOMY  FOE 
FAULTY  ANCHYLOSIS  OF 
THE  HIP. 

A,  Intracapsular ;    B,   Ex- 
tracapsular. 


564  OPERATIVE    SURGERY. 

In  severe  and  old-standing  cases  the  mere  division  of  the 
bone  may  possibly  not  suffice  to  correct  the  deformity,  and 
it  may  be  necessary  to  cut  contracted  tendons  or  contracted 
bands  of  fascia.  The  tendons  most  usually  in  need  of 
tenotomy  are  those  of  the  adductor  longus,  rectus,  and 
sartorius. 

In  the  operations  upon  the  neck  of  the  bone  it  is  assumed 
that  the  division  takes  place  within  the  capsule. 

Of  the  two  methods  described — viz.,  that  of  division  of  the 
neck,  and  that  of  division  of  the  shaft — the  latter  may  be  said 
in  general  terms  to  be  the  better.  It  is  certainly  the  simjoler 
and  the  easier  operation.  It  has  been  asserted  that  Gant's 
operation  leads  to  more  shortening,  but  the  statement  does 
not  appear  to  be  well  founded,  and  shorteniug  is  largely  a 
question  of  after-treatment. 

In  Adams'  operation  the  saw  is  apt  to  travel  beyond  the 
neck  and  be  carried  through  some  part  of  the  shaft. 

"  If  the  bone  be  dense,"  writes  Jacobson,  "  from  previous 
inflammation,  and  the  section  trenches  upon  the  shaft  instead 
of  going  through  the  neck  only,  the  sawing  may  be  very 
tedious.  Thus  I  have  t\vice  seen  cases  in  which  this  took 
over  half  an  hour." 

Adams'  operation  is  only  applicable  to  cases  in  which  the 
nejk  of  the  femur  has  remained  unaltered,  e.g.,  in  anchylosis 
after  rheumatic  fever. 

In  many  instances  there  is  practically  no  neck  to  the 
bone,  or  there  is  an  immense  mass  of  thickened  tissue  in 
the  position  of  the  old  capsule,  or  the  head  of  the  femur  lias 
been  displaced  upon  the  dorsum. 

After  division  of  the  neck  considerable  deformity  ma}'  still 
persist,  owing  to  extreme  contraction  of  the  psoas  and  iliacus 
muscles. 

Volkmann  advised  the  removal  of  a  cuneiform  piece  of 
bone  from  the  shaft  below  the  trochanters,  as  the  best  means 
of  dealing  with  cases  of  anchylosis  of  the  hip  {Gentralhlatt  filr 
Chirurgie,  No.  1,  1874),  but  linear  osteotomy  has  been  shown 
to  be  in  every  case  sufficient. 


565 


CHAPTER    III. 

Osteotomy  for  Genu  Valgum. 


,-Ssrsi' 


i;» 


Anatomical  Points. — In  the  severer  forms  of  genu  valgum 
— and  it  is  in  these  only  that  osteotomy  is  practised — there  is 
a  great  increase  in  the  size  and  depth  of  the  internal  condyle. 
This  is  due — as  has  been  shown  by 
Mickuhcz — to  an  increase  in  the  dia- 
pliysis  of  the  bone   rather   than  in 
the  epiphj^sis  (Fig.  15.5). 

The  position  and  limits  of  the 
lower  epiphysis  of  the  femur  are 
dealt  with  in  the  chapter  on  excision 
of  the  knee.  It  is  only  necessary 
here  to  repeat  that  the  epiphyseal 
line  is  about  on  a  level  with  the 
tubercle  for  the  adductor  magnus 
tendon.  The  trochlear  surface  of  the 
femur  belongs  to  the  epiphysis. 

A  transverse  section  of  the  fe- 
mur about  the  epiphyseal  line  AviU 
show  that  the  outer  part  of  the  bone 
is  much  more  extensive  than  the 
inner  part,  and  this  disproportion  is 
continued  for  some  Httle  distance 
upwards  in  the  less  expanded  part 
of  the  bone  (Fig.  156).  The  medul- 
lary canal  ceases  some  way  above  the 

point  at  which  the  shaft  of  the  bone  widens  out  to  form 
the  condyloid  extremity.  Indeed,  none  of  these  operations 
concern  the  canal. 

The  sjmovial  membrane  of  the  knee-joint  extends  upwards 
as  a  large  cul-de-sac  above  the  patella  and  beneath  the 
extensor  tendon.     This  cul-de-sac  is  somewhat  triangular,  has 


Fig.  155.  — VERTICAL  SECTIOX  OF 
THE  LOWER  END  OF  A  DE- 
FORMED FEMUR,  FROM  AN 
EXTREME  CASE  OP  GENU 
VALGUM. 

A,  Line  of  epiphysis ;  B,  Trans- 
verse line  drawn  at  level  of 
adductor  tubercle ;  C.  Line 
of  Macewen's  operation. 


5«6 


OPERATIVE    SURGERY. 


Fig.  156. — TEANSVEKSE  SECTION  OF 
THE  FEMUE  ABOUT  THE  LEVEL  OP 
THE  EPIPHYSEAL  LINE,  SHOWING 
THE  TEIANGULAE  OUTLINE  OF  THE 
BONE. 

A,  P,  E,  1,  Anterior,  posterior,  exter- 
nal, and  internal  surfaces. 


its  base  at  the  condyles  and  its  narrowest  part  uppermost. 
and  reaches  a  point  an  inch  or  more  above  the  upper  margin 
of  the  trochlear  surface  of  the  femur. 

When  the  knee  is  bent,  the  cul-de-sac  is  drawn  down. 
Above  the  spiovial  pouch  is  a  bursa,  which  hes  upon  the 
bone   and  measures  about   one   inch  vertically.     This  bursa 

communicates  with  the  knee- 
joint  in  about  seven  cases  out 
of  ten. 

In  certain  of  these  operations 
the  position  of  the  anastomotica 
magna  artery  must  be  borne  in 
mind. 

The  following  o'perations  wiU 
be  described : — 

1.  Osteotomy  of  the  shaft  of 
the  femur  from  the  outer  side. 

2.  Macewen's  supra-condyloid 
operation. 

3.  Ogston's  operation  by  dividing  the  internal  condyle. 

1.  Osteotomy  of  the  Shaft  of  the  Femur  from  the  Outer 
Side. 

Operation. — The  patient  lies  upon  the  back,  with  the  knee 
flexed  over  a  sand-bag,  ujDon  which  the  limb  is  made  to  rest 
securely.  The  surgeon  should  stand  to  the  inner  side  of  the 
limb,  i.e.,  between  the  patient's  legs.  An  assistant  standing 
opposite  to  him  steadies  the  limb. 

The  thigh  being  adducted  so  as  to  well  expose  the  outer 
surface  to  the  operator  (as  he  stands  to  the  mner  side  of  the 
knee-joint),  an  incision  about  one  inch  in  length  is  carried 
down  to  the  bone  at  a  point  about  two  inches  above  the 
external  condyle.  The  incision  is  made  upon  the  outer  side 
of  the  thigh,  is  transverse — i.e.,  at  right  angles  to  the  long  axis 
of  the  femur — and  may  be  made  in  one  cut.  The  knife  passes 
through  the  iho-tibial  process  of  the  fascia  lata,  and  runs  in 
front  of  the  biceps  muscle. 

When  the  loiife  is  withdrawn,  the  osteotome  is  inserted, 
and  tlic  limb — no  longer  adducted — is  firmly  planted  upon 
the  sand-bag.  The  osteotome  is  made  to  traverse  the  shaft 
transversely.     As  the  outer  part  of  the  bone  is  here  thicker 


OSTEOTOMY  FOR   GENU   VALGUM.  5(J7 

than  the  inner  part,  it  will  be  found  that  when  two-thirds  of 
the  shaft  have  been  divided  the  bone  can  usually  be  readily 
fractured.  It  is  essential  that  the  division  be  extensive 
enough,  and  that  no  premature  and  violent  attempts  be  made 
to  complete  the  division  of  the  bone. 

Comment — This  operation  is  simple,  although  the  position 
of  the  surgeon  is  a  Httle  inconvenient. 

The  bone  is  divided  at  a  much  narrower  part  than  m  the 
supra-condyloid  operation  next  to  be  described ;  the  osteotom}- 
is  therefore  easier  and  more  quickly  performed. 

There  is  no  danger  of  the  chisel  wandering  into  the  wide 
expanse  of  bone  which  makes  up  the  external  condyle. 

The  bone  section  is  far  removed  from  the  epiphyseal  line, 
and  is  also  at  a  distance  from  the  synovial  sac  of  the  knee- 
joint. 

No  blood-vessels  of  any  importance  come  in  the  line  of  the 
incision. 

2.  Macewen's  Supra-condyloid  Operation. 

Opi'vation. — The  patient  lies  upon  the  back,  close  to  the 
edge  of  the  table.  Both  hip  and  knee  are  flexed ;  the  thigh 
is  abducted  and  rests  upon  its  outer  side.  The  knee  is  well 
fixed  upon  the  sand-pillow.  The  surgeon  places  himself  upon 
the  outer  side  of  the  limb.  One  assistant,  standing  upon  the 
opposite  side  of  the  table  to  the  operator,  steadies  the  limb  by 
the  thigh,  while  a  second  assistant  at  the  foot  of  the  table 
takes  hold  of  the  upper  part  of  the  leg. 

The  following  is  Macewen's  description  (Heath's  "Dic- 
tionary of  Surgery,"  vol.  ii.,  page  143) : — 

"  A  sharp-pointed  scalpel  is  introduced  on  the  inside  oi 
the  thigh,  at  a  point  where  the  two  following  lines  meet — one 
drawn  transversely,  a  finger's-breadth  above  the  superior  tip 
of  the  external  condyle,  and  a  longitudinal  one  drawn  half  an 
inch  in  front  of  the  adductor  magnus  tendon.  The  scalpel  here 
penetrates  at  once  to  the  bone,  and  a  longitudinal  incision 
(a.  Fig.  157)  is  made,  sufficient  to  admit  the  largest  osteotome 
and  the  finger,  should  the  surgeon  deem  it  necessary.  Before 
withdrawing  the  scalpel,  the  largest  osteotome  is  slipped  by  its 
side  until  it  reaches  the  bone. 

"  The  scalpel  is  witlidrawn,  and  the  osteotome,  which  was 
introduced   longitudinally,    is    now    turned    transversely    in 


568 


OPERATIVE    SURGERY. 


the  direction  required  for  the  osseous  incision  (b  Fig.  157) 
In  turning  the  osteotome,  too  much  pressure  must  not  be 
exerted,  lest  the  periosteum  be  scraped  oft".  It  is  then  con- 
venient to  pass  the  edge  of  the  osteotome  over  the  bone 
until  it  reaches  the  posterior  internal  border,  when  the  entire 
cutting  edge  of  the  osteotome  is  ap- 
plied, and  the  instrument  is  made  to 
penetrate  from  behind  forwards,  and 
towards  the  outer  side. 

"After  completing  the  incision  in 
that  direction,  the  osteotome  is  made 
to  traverse  the  inner  side  of  the  bone, 
cutting  it  as  it  proceeds,  until  it  has- 
divided  the  uppermost  part  of  the  in- 
ternal border,  when  it  is  directed  from 
before  backward  towards  the  outer  pos- 
terior anoie  of  the  femur. 


D 
Fig.      157.  - 

OPERATION 
VALGUM. 

A,  Skin  incision : 
tome  incision 
phj'seal  line  ; 
condyle. 


In  cutting  on  these  lines  there  is- 


MACE  WEN'S 
FOE       GENU 

B,  Osteo- 

;    c,   Epi- 

D,    Inner 


no  fear  of  injuring  the  femoral  artery. 
The  bone  may  be  divided  without 
paying  heed  to  this  order  of  procedure, 
but  it  is  better  that  the  operator  should 
have  a  definite  plan  in  his  mind,  so 
that  he  may  be  certain  as  to  what  has 
been  divided  and  what  remains  to  be  done.  The  writei-  is 
persuaded  that  accidents  have  happened  by  not  paying  heed 
to  this.  In  using  the  osteotome,  the  left  hand,  in  which  it  is 
grasped,  ought  to  give,  after  each  impulse  supplied  by  the 
mallet,  a  slight  movement  to  the  blade — not  transversely  to 
its  axis,  but  longitudinally— so  as  to  prevent  any  disposition 
to  fixity  Avhich  it  might  assume. 

"  After  the  inner  portion  of  the  bone  is  divided,  a  finer 
instrument  may  be  slipped  over  the  first,  which  is  then  with- 
drawn ;  and  even  a  third,  if  necessary,  may  take  the  place  of 
the  second  when  the  outer  portion  of  the  bone  comes  to  be 
divided.  ^Vhether  one  or  more  osteotomes  be  used  depends 
much  on  the  resistance  met  with.  If  the  tissue  is  yielding, 
one  may  suffice ;  if  hard  or  brittle,  two  or  three  will  effect  the 
division  more  easily  and  with  less  risk  of  breaking  or  splitting 
the   bone   longitudinally.     In   the   adult   the   dense  circum- 


OSTEOTOMY  FOR    GENU    VALGUM.  'm 

ferential  layer  of  bone  resists  the  entrance  of  the  osteotome 
at  the  outset,  but  several  strokes  cause  the  instrument  to 
penetrate  this  superficial  dense  portion,  when  it  will  pass 
easily  through  the  cancellated  tissue. 

"  After  a  little  experience,  the  surgeon  recognises,  by  touch 
and  sound,  when  the  osteotome  meets  the  hard  layer  on  the 
outer  aspect  of  the  bone.  If  it  be  considered  desu-able  to  notch 
or  penetrate  this  outer  dense  part  of  the  bone,  in  doing  so 
the  osteotome  ought  to  be  grasped  firmly  by  the  left  hand, 
the  inner  border  of  the  hand  resting  on  the  limb,  so  as  to 
check  instantly  any  impetus  which  may  be  considered  too  great. 
It  is  better  to  snap  or  bend  this  layer  rather  than  cut  it. 

"  When  the  instrument  is  to  be  altered  in  position,  it  ought 
not  to  be  pulled  out  in  the  ordinary  wa}^  as  it  is  then  liable  to 
be  removed  from  the  wound  in  the  soft  parts,  as  well  as  from  the 
bone.  Instead,  let  the  left  hand,  with  its  inner  border  resting 
on  the  limb,  grasp  the  instrument,  while  the  thumb  is  pressed 
under  the  ridge  afforded  by  the  rounded  head,  and  gently 
lever  the  osteotome  outwards  by  an  extension  movement 
of  the  thumb.  In  this  way  the  movement  may  be 
regulated  with  precision.  It  is  desirable  to  complete  all  the 
work  intended  by  the  osteotome  before  removing  it  from  the 
wound. 

"When  the  operator  thinks  that  the  bone  has  been 
sufficiently  divided,  the  osteotome  is  laid  aside  and  a  sponge 
saturated  in  1-40  carbolised  watery  solution  is  placed  over  the 
wound.  While  the  surgeon  holds  the  sponge,  he  at  the  same 
time  employs  that  hand  as  a  fulcrum;  with  the  other  he 
grasps  the  limb  lower  down,  using  it  as  a  lever,  an' I  jerks  if 
the  bone  be  hard,  or  bends  slowly  if  the  bone  be  soft,  in  an 
inward  direction,  when  the  bone  will  snap  or  bend  as  the 
case  may  be." 

Neither  sutures  nor  drainage-tubes  are  required. 

For  the  after-treatment,  see  previous  chapters. 

Go7)i7)ient. — The  highest  part  of  the  articular  surface  of 
the  femur  is  a  good  guide  to  the  level  of  the  lowest  part  of 
the  incision. 

Great  care  must  be  taken  that  the  line  of  the  bone- 
incision  is  appreciated  and  accurately  followed. 

In    normal  limbs — as  Dr.   Macewen  points   out — a   line 


570  OPERATIVE    SURGERY. 

dra-vvn  transversely  across  the  bone  from  the  adductor 
tiibercde  Avill  pass  into  the  middle  of  the  external  condyle, 
whereas  in  the  femur  in  a  case  of  severe  genu  valgum  such  a 
Une  "would  pass  into  the  upper  part  of  that  condyle  (b,  Fig. 
155).  If  the  osteotome  be  not  carefully  directed,  it  is  apt  to  land 
in  the  wide  tract  of  bony  tissue  forming  the  outer  condyle. 

Again  Dr.  Macewen  writes :  "  For  a  short  distance  above 
the  condyles  the  femur  has  a  much  thicker  outer  than  inner 
border ;  in  many  instances  the  outer  is  twice  as  thick  as  the 
inner, 

"  If  the  form  of  the  bone  be  not  borne  in  mind,  the  surgeon 
may  think  that  he  has  divided  it  sufficiently,  and  yet  he  may 
find  that  it  will  not  yield,  owing,  in  most  cases,  to  the  posterior 
outer  part  remaining  intact." 

In  young  subjects  up  to  fifteen  or  sixteen,  the  division  of 
the  internal  two-thirds  of  the  bone  will  usually  suffice,  the 
remainder  being  broken  ;  but  in  adults,  especially  when  the 
bone  is  hard  and  brittle,  the  section  should  be  more  complete, 
and  as  httle  fracturing  should  be  attempted  as  is  possible. 

In  children  one  osteotome  wiU  suffice  for  the  division  of 
the  bone. 

If  care  be  not  exercised,  it  is  possible  for  the  femur  to  be 
split  longitudinally. 

The  incision  employed  is  above  the  level  of  the  articular 
hgaments. 

The  cut  in  the  soft  parts  may  be  made  transversely,  and 
be  so  placed  as  to  correspond  to  the  intended  bone  incision.  By 
this  means  the  osteotome  is  more  readily  introduced  and  more 
easily  re-inserted  should  it  be  accidentally  removed  during  the 
operation.  The  transverse  incision  spares  the  soft  parts  from 
a  certain  amount  of  bruising  and  disturbance,  but  it  docs  not 
favour  so  complete  a  subcutaneous  method. 

Although  the  synovial  pouch  of  the  knee-joint  reaches  as 
high  as  the  level  of  the  bone  incision,  it  is  not  in  the  way  of 
tlie  actual  wound  itself,  since  it  tapers  to  the  middle  hue  as  it 
ascends.  A  certain  amount  of  fat  intervenes  between  the 
synovial  pouch  and  the  bone,  and  the  osteotomy  cut  is 
posterior  to  the  pouch. 

There  is  but  little  bleeding.  The  femoral  artery  cannot  be 
in  danger.     If  the  knee  be  well  flexed,  the  popliteal  vessels  aie 


OSTEOTOMY  FOR    GENU   VALGUM.  571 

placed  as  far  as  possilile  away  fi'om  the  operation  area.  The 
wound  is  above  the  superior  internal  articular  artery,  and 
bslow  and  anterior  to  the  anastomotica  magna.  Bleeding 
from  this  vessel  has,  however,  been  reported  as  occurring 
during  the  operation. 

In  making  the  surface-wound,  branches  of  the  internal 
cutaneous  nerve  can  scarcely  be  avoided,  and  some  tributaries 
to  the  internal  saphenous  vein  may  be  cut.  The  incision  is 
anterior  to  the  inner  series  of  tendons  about  the  knee,  and  the 
least  amount  of  injury  is  inflicted  upon  the  soft  parts,  so  far 
as  actual  cutting  is  concerned,  when  the  incision  is  longi- 
tudinal, as  described  in  the  account  of  the  operation. 

The  comparative  value  of  Macewen's  operation  will  be 
considered  in  commenting  upon  the  next  procedure. 

3.  Ogston's  Operation  by  dividing  the  Internal  Con- 
dyle. 

Operation. — The  patient  is  supine.  The  hip  and  knee  are 
flexed  (the  latter  fully  flexed),  and  the  sole  of  the  foot  rests 
upon  the  table.  The  knee-joint  is  supported  upon  a  sand 
pillow.  The  surgeon  stands  in  every  case  on  the  left  side  of 
the  patient,  and  steadies  the  limb  with  his  left  hand.  One  or 
more  assistants  hold  the  extremity  and  fix  it  in  position. 

A  point  is  selected  on  the  anterior  and  inner  aspect  of  the 
femur,  about  an  inch  above  the  upper  limit  of  the  articular 
surface  of  the  femur.  A  long  tenotome  is  here  introduced 
flatly,  and  is  pushed  downwards,  forwards  and  outwards,  untU 
the  point  is  felt  in  the  inter-condyloid  space.  The  cutting 
edge  of  tlie  tenotome  is  now  turned  towards  the  femur,  and  as 
the  instrument  is  withdrawn  the  tissues  in  the  line  of  the  deep 
incision  are  divided  down  to  the  bone. 

An  Adams'  saw  is  now  thrust  along  the  track  made  by  the 
tenotome,  and  should  point  directly  towards  the  crucial 
ligaments.  If  the  patella  can  be  displaced  suflSciently  out- 
wards, the  point  of  the  saw  may  be  felt  in  the  inter-condyloid 
groove. 

The  internal  condyle  is  now  sawn  through  from  above 
downwards,  and  from  before  backwards,  and  when  nearly 
severed  the  saw  is  withdrawn,  the  wound  covered  by  a  carbol- 
ised  sponge,  and  the  separation  of  the  condyle  completed  by 
drawing  the  extended  leg  forcibly  inwards.     The  loose  condyle 


572 


OPERATIVE    SURGERY. 


can  then  be  felt  to  be  displaced  upwards  over  the  sawn  surface 
of  the  femur  (Fig.  158). 

Neither  drainage-tube  nor  sutures  are  required. 
The  operation  has  been  performed  by  the  chisel  instead  of 
by  the  saw. 

No  vessels  of  any  magnitude  ought  to  be  wounded,  but 

there  may  be  considerable  oozing  from  the  cut  surface  of  the 

bone.     Very  great  care  must  be  taken 

that  the  saw  does  not  travel  into  the 

popliteal  space. 

Comment. — This  operation  has  been 
practically  abandoned  in  favour  of  one 
of  the  two  other  methods  described. 
Indeed,  Professor  Ogston  himself  has 
expressed  a  preference  for  Macewen's 
operation  in  the  place  of  the  procedure 
known  by  his  name. 

The  objections  to  Ogs ton's  operation, 
when  compared  with  the  two  other 
methods,  are  these :  The  joint  is  opened 
up,  the  synovial  membrane  is  torn,  and 
both  blood  and  bone-dust  can  find 
their  way  into  the  articular  cavity.  Spiovitis  and  stiffness  of 
the  joint  may  therefore  result.  The  posterior  crucial  ligament 
is  damaged  by  the  saw,  the  epiphyseal  line  is  cut  through, 
and  a  very  large  section  of  cancellous  bone  is  produced. 

In  the  other  operations  the  joint  is  not  opened,  the  wound 
is  free  from  bone-dust,  no  ligaments  are  interfered  with,  the 
epiphysis  is  not  encroached  upon,  and  the  bone  section 
involves  a  comparatively  small  area. 

With  regard  to  the  first  two  operations  described — viz. 
osteotomy  of  the  shaft  and  Macewen's  operation — the  points 
which  have  been  urged  in  favour  of  the  former  procedure  have 
been  detailed  in  the  comment  made  upon  that  measure.  The 
special  advantages  which  are  claimed  for  the  supra-condyloid 
osteotomy  are  these  : — The  bone  is  divided  nearer  to  the 
seat  of  the  deformity,  and  the  sections  of  bone  left  by  the 
osteotome  are  sufficiently  wide  to  allow  of  their  being  brought 
well  together  and  kept  in  safe  contact  din-ing  the  progress  of 
the  after-treatment. 


Fig.  lo8.— ogston'sopeea 

TION  FOE  GENU  VALGtrM. 


573 


CHAPTER    IV. 

OSTEOTOlVrY   FOR  FaULTY    ANCHYLOSIS   OF  THE   KnEE-JoINT. 

This  operation  is  carried  out  in  cases  of  angular  anchylosis 
of  the  knee  in  Avhich  the  deformity  is  considerable,  in  which  a 
less  complete  measure  would  be  ineffectual,  and  m  which  no 
active  disease  is  present. 

Operation. — The  femur  is  divided  at  the  same  level  and  in 
the  same  manner  as  in  Macewen's  operation.  The  osteotome, 
however,  is  made  to  divide  the  anterior  part  of  the  bone  in  its 
<'ntire  breadth,  and  is  so  manipulated  that  the  posterior 
laminte  of  the  femur  are  alone  left  unsevered.  When  this  has 
been  effected,  the  bone  is  straightened  from  behmd  forwards, 
the  remaining  part  of  the  osseous  tissue  giving  way  under  the 
gradual  pressure  applied. 

Great  care  must  be  taken  that  the  osteotome  is  not  driven 
through  the  bone  into  the  popliteal  space. 

The  limb  is  adjusted  as  for  fractured  femur,  and  is  most 
conveniently  placed  upon  a  Macintyre's  splint. 

It  will  seldom  be  safe  or  possible  for  the  fully-extended 
p  jsition  to  be  assumed  at  once.  The  limb  is  therefore  put 
up  in  the  posture  of  slight  flexion. 

Comment. — If  the  deformity  be  such  that  the  femur  and 
tibia  form  nearly  a  right  angle  with  one  another,  then  it  is 
improbable  that  mere  linear  osteotomy  of  the  femur  ^vill  suffice 
to  correct  the  deviation. 

In  such  a  case  it  may  be  necessary  to  remove  a  wedge 
from  the  anterior  surface  of  the  femur,  or  to  carry  out  a  double 
linear  osteotomy — as  Macewen  advises — viz.,  the  division  of 
the  femur  as  above  described,  and  a  division  of  the  tibia  just 
below  its  tuberosities  (page  515). 

In  these  cases  of  extreme  deformity  great  care  must  be 
taken  in  extending  the  limb  after  the  operation.     The  tissues 


574  OPERATIVE    SURGERY. 

of  the  popliteal  region  will  be  miich  contracted,  and  a  gradual 
straii^htening  of  the  limb,  extending  over  a  week  or  more,  and 
associated  possibly  with  the  division  of  certain  tendons  and 
bands  of  fascia,  will  be  advisable.  In  general  terms,  it  may  be 
said  that  the  limb  may  be  extended  with  safety  so  long  as  the 
tibial  arteries  pulsate  freely  at  the  ankle. 


675 


CHAPTER    V. 

Osteotomy  of  the  Tibia. 

Under  this  title  three  operations  will  be  described : — 

1.  Linear  osteotomy  just  below  the  tuberosities. 

2.  Linear  osteotomy  for  bent  tibia. 

3.  Cuneiform  osteotomy  for  bent  tibia. 

1.  Osteotomy  of  the  Tibia  just  below  the  Tuberosities. 

This  operation  is  carried  out  in  the  treatment  of  exceptional 
cases  of  faulty  anchylosis  of  the  knee-joint,  as  mentioned  in 
the  previous  chapter. 

Operation. — The  leg  is  firmly  fixed  upon  the  sand-pillow 
with  the  anterior  surface  well  exposed.  In  every  case  the 
surgeon  stands  to  the  outer  side  of  the  limb  to  be  dealt 
with. 

A  spot  is  selected  just  below  the  tubercle  of  the  tibia,  and 
a  transverse  incision  of  the  necessary  width  is  made  over  the 
anterior  tibial  border.  The  osteotome  is  introduced  and  the 
bone  divided  transversely. 

The  instrument  attacks  first  the  anterior  aspect  of  the 
bone,  and  then  follows  the  internal  surface  until  the  posterior 
aspect  is  reached.  The  inner  segment  of  the  bone  having 
been  thus  divided  from  before  backwards,  the  instrument  is 
now  so  directed  as  to  cut  from  within  outwards.  In  this  way 
all  the  bone  may  be  divided  with  the  exception  of  its  posterior 
lamellae,  which  are  fractured  by  pressure  applied  in  the 
antero-posterior  plane. 

Great  care  must  be  taken  of  the  tissues  which  skirt  the 
external  surface  of  the  tibia. 

The  great  vessels  at  the  back  of  the  limb  are  well  protected 
by  the  popliteus  muscle  and  the  fascia  which  covers  it, 
although  in  cases  of  long-standing  anchylosis  the  muscle  will 
be  much  atrophied. 

The  fibula  does  not  require  to  be  divided. 


57U  OPEBATIVh    SURGBEY. 

2,  Linear  Osteotomy  for  Bent  Tibia. 

This  operation  will  suffice  for  the  larger  proportion  of  cases 
of  bent  tibia.  Mr.  Jacobson  considers  it  to  be  especiall}^ 
applicable  to  cases  in  which  the  bone  is  bent  laterally,  and  in 
which  the  bend  is  most  marked  at  the  junction  of  the  middle 
and  lower  thirds. 

The  section  of  the  bone  is  most  usually  transverse  (Fig. 
159). 

Mr.  Barker  advises  an  oblique  division  of  the  bone.  The 
plane  of  the  oblique  hne  of  section  must  vary  with  the 
direction  of  the  tibial  curve.  If  convex  inwards,  the  bone  is 
divided  from  above  downwards,  and  from  before  backwards ; 
if  curved  forwards,  the  plane  of  section  should  be  from  above 
downwards,  and  from  within  outwards.  It  is  maintained 
that  these  Unes  of  section  permit  the  deformity  to  be  cor- 
rected with  the  least  possible  displacement  of  the  fractured 
surfaces. 

Operation. — 1.  If  the  osteotome  be  employed,  the  pro- 
cedure is  carried  out  in  the  manner  already  described,  the 
situation  of  the  incision  depending  upon  the  position  of  the 
bone  section.  The  site  of  the  nutrient  canal  of  the  tibia  Avith 
its  large  blood-vessel  must  be  borne  in  mmd.  In  all  but  very 
exceptional  instances,  the  bone  section  will  be  found  to  be 
below  the  site  of  the  canal.  The  nutrient  artery  runs  down- 
wards in  the  bone. 

2.  If  the  saw  be  employed,  the  operation  may  be  carried 
out  as  described  by  Mr.  Jacobson  : — 

"  The  parts  being  cleansed,  and  the  limb  resting  on  its 
outer  side  on  a  firm  sand-bag,  the  surgeon  notes,  at  the 
anterior  and  inner  margins  of  the  tibia,  the  spot  where  the 
curve  is  sharpest.  Fixing  his  left  index  over  the  inner 
margin,  he  enters  a  long  tenotome  or  narrow  bistoury  exactly 
over  the  crest  of  the  tibia,  sends  it  down  under  the  skin,  over 
the  inner  surface  of  the  bone,  till  its  point  is  felt  just  beneath 
the  tinker;  it  is  here  puslicd  through  the  skin  to  make  a 
counter-puncture  for  drainage.  The  knife,  hitherto  held 
horizontally,  is  now  turned  vertically,  and  cuts  firmly  on  the 
bone,  dividing  the  periosteum — thick  in  these  cases — in  one 
line  ri"ht  across  the  inner  surface  of  the  tibia.  As  the  knife 
is  withdrawn,  it  is  made  to   enlarge  the  wound  of  entrance 


OSTEOTOMY  FOE  BENT  TIBIA. 


bll 


slightly,  to  make  room  for  the  saw.  This  (Adams')  is  now 
introduced  in  the  same  way  as  the  knife,  carried  horizontally 
down  to,  but  not  through,  the  puncture  through  the  skin  on 
the  inner  border  of  the  tibia.  The  left  index  keeping  guard 
at  this  spot,  the  saw  is  turned  towards  the  bone,  and  cuts 
through  the  inner  two-thirds  of  it.  The  entrance  of  the  saw 
into  cancellous  tissue   can   be   known  by  the  diminution  of 


A  B 

Fig.  159. — Diagram  representing  a  curved  tibia — A,  Withi  a  wedge  removed  for  the 
purpose  of  straightening  the  bone ;  B,  The  same  with  the  bone  straightened ;  c, 
The  same  with  the  bone  simply  divided  and  straightened.     {Modijiedfrom  Little.) 

resistance  and  the  increased  bleeding  which  often  occurs ;  but 
the  best  test  of  the  depth  to  which  the  operator  has  arrived 
is  the  depth  of  the  groove  in  which  the  saw  has  sunk. 

"  When  the  bone  is  sawn  sufficiently,  carbolised  hnt  is 
placed  on  the  wound,  and  the  surgeon,  firml}'  placing  his  two 
hands  close  together,  immediately  above  and  below  the 
wound,  sharply  carries  the  lower  fragment  outwards. 

"  If  the  saw  has  been  sufficiently  used,  the  tibia  snaps 
distinctly,  and  the  fibula  yields  with  a  '  green-stick '  sen- 
sation. Great  care  must  be  taken  to  exert  the  force  just  on 
the  sawn  portion,  or  the  ligaments  of  the  ankle  or  superior 
tibio-fibular  joint  maybe  strained  and  damaged.  ...  A 
horsehair  drain  should  be  inserted." 


578 


OPERATIVE    SURGERY. 


Comment. — Of  these  two  methods,  the  former  should  be 
selected  whenever  possible,  for  the  reasons  which  have  been 
already  given  (page  558). 

3.  Cuneiform  Osteotomy  for  Bent  Tibia. 

This  operation  is  carried  out  in  the 
manner  already  described  (page  558).  The 
base  of  the  wedge  will  usually  correspond 
to  the  crest  of  the  tibia  (Fig.  160),  and  will 
measure  about  three-quarters  of  an  inch  in 
breadth. 

OSTEOTOMY   FOR   HALLUX   VALGUS. 

In  aggravated  cases  of  hallux  valgus 
the  condition  may  be  remedied  by  the  follow- 
ing simple  operation,  described  by  Mr.  Barker 
("  Manual  of  Surgical  Operations,"  page  99). 
The  originator  of  the  operation  was  a  student 
of  University  College  Hospital. 

Operation. — The  patient  Ues  upon  the 
affected  side ;  the  foot  is  supported  upon  a 
sand-pillow,  and  is  firmly  held  with  its  inner 
border  turned  upwards. 

"  The  head  of  the  metatarsal  bone  of 
the  great  toe  is  defined  by  feeling  with  the 
fingers,  and  an  incision  about  an  inch  long  is 
made  on  its  inner  side,  commencing  over  the 
margin  of  the  cartilage,  and  dividing  everything  down  to  the 
periosteum,  to  the  full  extent  of  the  incision.  Through  the 
latter  the  chisel  is  inserted,  and  then  turned,  so  that  its  edge 
shall  be  across  the  neck  of  the  bone,  at  a  point  about  half  an 
inch  from  the  head.  A  few  strokes  of  the  mallet  will  now 
divide  the  bone  almost  through,  the  remainder  being  left  for 
forcible  fracture.  The  chisel  is  then  withdrawn,  while  a 
sponge  is  pressed  round  its  blade,  and  with  the  sponge  still 
pressed  tightly  on  the  wound,  this  toe  is  forcibly  brought 
inwards  into  a  straight  line.  A  slight  antiseptic  dressing, 
covered  by  a  straight  splint  for  the  inside  of  the  foot,  to 
which  the  toe  is  secured,  completes  the  procedure.  If  there 
be  any  difficulty  in  bringing  the  toe   into  a  straight  line,  a 


Fig.     160.— ctTNEi- 

FOEM  OSTEOTOMY 
FOE  CTTEVED  TI- 
BIA, 


OSTEOTOMY  FOB  HALLUX  VALGUS.  579 

small  wedge  may  be  removed  from  the  bone,  instead  of  its 
simple  section,  after  which  the  difficulty  will  disappear." 

ComvieTit. — No  structures  of  importance  are  divided,  and 
no  sutures  are  necessary. 

Excision  of  the  metatarso-phalangeal  joint  has  been  per- 
formed for  the  relief  of  hallux  valgus,  but  the  operation  is 
needlessly  severe,  and  is  in  every  way  inferior  to  the  measure 
just  described. 


L  L  2 


580 


CHAPTER    VI. 

Cuneiform  Osteotomy  for  Inveterate  Club-Foot. 

In  this  operation  a  wedge-shaped  piece  of  bone  is  removed 
from  the  outer  side  of  the  foot  at  the  site  of  the  medio-tarsal 
joint. 

The  cases  selected  for  this  method  of  treatment  are  ex- 
amples of  very  extreme  and  intractable  club-foot,  which  have 
resisted  treatment  by  tenotomy,  manipulation  and  ajDparatus, 
which  are  associated  with  distinct  changes  in  the  shapes  of 
the  tarsal  bones,  and  in  which  it  is  evident  that  no  step  short 
of  the  removal  of  osseous  tissue  can  alter  the  shape  of  the  foot. 

The  rudiment  of  the  present  operation  dates  from  1854,  in 
which  year  Dr.  Little  suggested  the  excision  of  the  cuboid  in 
severe  tahpes  equino-varus,  and  Mr.  Solly  performed  the 
actual  operation  involving  the  removal  of  that  bone  {Med.- 
Chir.  Trans.,  1857,  page  118).  Mr.  Davies-CoUey  removed  a 
wedge-shaped  piece  of  the  tarsus  in  1878,  but  with  Mr.  Davy 
must  rest  the  credit  of  having  formulated  the  present  opera- 
tion, and  of  having  illustrated  it  by  a  number  of  cases  {Med- 
Chir.  Trans.,  1885,  page  139). 

The  Size  of  the  Wedge. — The  dimensions  of  the  portion  of 
bone  removed  must,  of  necessity,  dej)end  upon  the  degree  of 
the  deformity.  In  talipes  equino-varus  the  base  of  the  wedge 
is  at  the  outer  side  of  the  foot,  and  is  mainly  represented  by 
the  cuboid  ;  the  apex  will  be  at  the  scaphoid  bone,  the  distal 
side  of  the  wedge  will  be  represented  by  a  line  at  right  angles 
to  the  metatarsal  bones,  and  the  proximal  side  by  a  line  at 
right  angles  to  the  long  axis  of  the  os  calcis. 

In  some  instances  the  wedge  is  composed  of  portions  of 
the  astragalus,  os  calcis,  scaphoid,  and  cuboid — the  last-named 
bone  predominating.  In  rarer  cases  it  is  found  to  contain 
portions  of  every  one  of  the  tarsal  bones,  and  the  bases  of  the 
four  outer  metatarsal  bones  also.     The  wedge  has  by  some 


OSTEOTOMY  FOR   CLUB-FOOT.  581 

surgeons,  notably  by  Mr.  Lund,  been  made  to  include  the 
astragalus  only. 

In  talipes  equinus  the  base  of  the  wedge  is  on  the  dorsum 
of  the  foot  and  its  apex  in  the  sole.  The  bones  represented 
in  the  wedge  are  portions  of  the  os  calcis,  astragalus,  scaphoid, 
and  cuboid  ;  and,  in  severe  cases,  portions  of  the  bones  anterior 
to  the  two  last-named  may  find  their  way  into  the  wedge. 

In  removing  a  wedge  of  ordinary  dimensions  no  important 
muscular  attachments  are  concerned.  Slips  from  the  tibialis 
posticus  will  have  to  be  severed,  and  the  origin  of  the  flexor 
brevis  hallucis  detached  from  the  cuboid.  The  latter  muscle 
will  probably  be  represented  by  atrophied  tissue. 

OPERATION   FOR   TALIPES   EQUINO-VARUS. 

The  patient  is  placed  upon  the  back,  with  the  hip  and 
knee  a  little  flexed,  and  the  sole  of  the  foot  resting  upon  a 
sand-pillow  on  the  table.  The  surgeon  stands  to  the  outer 
side  of  the  limb,  and  an  assistant  opposite  to  him  grasps  the 
foot  and  leg,  and  steadies  the  extremity  or  moves  it  as  re- 
quired.    The  operation  is  usually  carried  out  as  follows : — 

The  outer  surface  of  the  foot  having  been  well  exposed, 
and  the  cuboid  defined,  an  oval  piece  of  skin  is  excised  from 
the  outer  side  of  the  foot  over  that  bone.  The  long  axis  of 
the  oval  will  be  in  the  long  axis  of  the  foot,  and  will  be  equal 
in  extent  to  the  base  of  the  wedge  of  bone  to  be  removed. 
This  piece  of  skin  will  include  the  mass  of  thickened  epi- 
dermis and  the  bursa  which  are  usually  found  over  the  cuboid. 

The  inner  side  of  the  foot  is  now  exposed,  and  at  the 
"  stereotyped  crease  of  skin,"  and  in  a  line  over  the  astragalo- 
scaphoid  joint,  a  vertical  cut  is  made  (from  dorsum  to  sole) 
of  sufficient  length  to  include  the  thickness  of  the  scaphoid 
bone.  At  this  incision  will  fall  the  apex  of  the  wedge  ;  its 
base  is  represented  by  the  part  from  which  the  skin  has  been 
already  removed. 

The  foot  is  now  firmly  fixed  so  as  to  bring  the  dorsum 
well  into  view,  and  with  an  elevator  the  tendons  and  all 
the  soft  parts  are  raised  from  the  dorsum  of  the  tarsus.  The 
elevator  is  introduced  through  the  outer  incision,  and  the 
surgeon  works  from  without  iuAvards.  The  instrument  must 
be  kept  close  to  the  bone,  and  the  area  to  be  represented  by 
the  wedge  must  be  laid  entirely  bare. 


582  OrEKATIVE    SURGERY. 

A  curved  director  or  a  slender  metal  spatula  is  now  intro- 
duced between  the  bones  and  tbe  soft  parts  which  have  been 
raised  from  the  dorsum.  This  instrument  is  used  for  the 
purpose  of  protecting  the  soft  parts  while  the  saw  is  being 
passed.  Its  extremity  should  present  at  the  inner  wound.  A 
tine  key-hole  saw  is  now  applied  to  the  bones,  and  a  wedge- 
shaped  piece  sawn  out.  Tije  saw  is  made  to  cut  from  the 
dorsum  towards  the  plantar  surface,  and  the  point  of  the  saw 
should  be  allowed  to  project  through  the  internal  wound. 
The  distal  side  of  the  wedge  should  be  sawn  first,  and  then 
the  ankle-joint  side.  The  director  or  protecting  spatula  is, 
of  course,  placed  over  the  saw  in  either  locahty. 

Great  care  must  be  exercised  as  the  saw  approaches  the 
tissues  of  the  sole.  The  wedge  is  now  seized  with  hon  forceps, 
and  is  loosened.  As  the  surgeon  drags  upon  it  with  the  left 
hand,  he  clears  the  plantar  surface  of  the  bones  to  be  removed 
with  a  narrow  scalpel  or  with  curved  scissors.  The  wedge 
can  usually  be  hfted  out  in  one  piece.  Any  hasmorrhage 
having  been  dealt  with,  the  portions  of  the  foot  are  brought 
together ;  and  if  the  deformity  be  not  fully  corrected,  a  little 
more  bone  may  be  removed  with  the  saw  or  with  a  chisel 
from  one  or  other  side  of  the  wedge-shaped  gap. 

The  large  gap  should  now  be  well  washed  out  by  a  stream 
of  water  firom  a  suitable  irrigator.  In  this  way  all  bone-dust 
and  debris  are  removed. 

The  wounds  are  closed  with  sutures,  and  a  drain  may  be 
introduced  into  the  lower  part  of  the  external  wound. 

It  is  not  necessary  that  the  bones  be  sutured  together. 
The  limb  is  finally  placed  upon  a  suitable  sphnt,  either  upon 
the  special  apparatus  designed  by  Mr.  Davy  or  upon  a  back 
splint  with  two  side  splints — the  outer  one  having  an  inter- 
ruption— such  as  would'  be  employed  in  the  treatment  of  a 
compound  fracture  of  the  foot.  A  large  sponge  dusted  with 
iodoform  forms  a  suitable  dressing.  There  will  probably  be 
mucli  oozing  at  first.     Primary  healing  may  be  anticipated. 

The  hmb  is  treated  as  if  it  were  the  seat  of  a  compound 
fracture  of  the  foot. 

Comment. — Mr.  Davy  employs  an  elastic  tourniquet  in 
performing  this  operation,  but  most  surgeons  will  prefer  to 
do  without  this  appliance.     It  is  quite  unnecessaiy. 


OSTEOTOMY  FOB   CLUB-FOOT.  683 

Mr.  Barker  would  substitute  for  the  removal  of  the  oval 
piece  of  skin  a  straight  incision  running  along  the  outer 
surface  of  the  cuboid  (from  the  neck  of  the  os  calcis  to  the 
base  of  the  tifth  metatarsal)  in  cases  where  there  is  little  or 
no  thickening  of  the  skin  over  the  cuboid. 

Mr.  Davy  employs  special  instruments,  viz.,  a  blunt  curved 
knife,  a  kite-shaped  director,  and  a  probe-pointed  saw;  but 
there  is  not  the  least  difficulty  in  the  way  of  performing  the 
operation  by  the  usual  surgical  instruments. 

Mr.  Jacobson  makes  a  T-shaped  incision  with  the 
horizontal  limb  along  the  outer  side  of  the  foot  over  the  os 
calcis  and  cuboid,  and  the  vertical  one  at  a  right  angle  to 
it,  passing  across  the  dorsum  and  ending  over  the  scaphoid. 
The  soft  parts  are  raised  as  flaps. 

In  performing  this  operation  I  have  in  all  cases  employed 
a  single  horizontal  incision,  and  have  made  no  use  of  an  inner 
wound.  I  have  cleared  the  bones  with  a  Farabeufs  ru2fine, 
and  have  made  the  section  of  the  bones  with  a  chisel  In 
most  of  the  cases  the  distal  bone  incision  has  been  through 
the  cuboid,  and  the  proximal  incision  through  the  neck  of  the 
OS  calcis.     The  apex  of  the  wedge  is  at  the  scaphoid. 

In  my  opinion  the  chisel  is  infinitely  to  be  preferred  to 
the  saw.  In  each  case  up  to  the  present  time  healing  by  first 
intention  has  followed. 

Results. — Union  should  be  firm  in  six  or  eight  weeks. 
Mr.  Dav}^  has  performed  twenty-six  operations,  with  one  death. 
The  average  stay  in  the  hospital  was  seventy-seven  days. 

All  the  patients  have  been  enabled  to  walk  and  perform 
the  daily  routine  of  work,  and  have  become  absolutely  planti- 
grade. A  useful  but  slightly  shortened  foot  results.  Move- 
ment in  the  ankle-joint  may  be  lost. 

In  some  cases  the  appHcation  of  a  fixed  dressing  has  been 
found  necessary  for  some  time  after  the  splint  has  been  re- 
moved.    In  others  a  high  boot  has  been  worn. 

OPERATION   FOR   TALIPES    EQUINUS. 

The  operation  carried  out  by  Mr.  Davy  m  this  form  of 
club-foot  differs  but  very  sUghtly  from  that  just  described, 
and  the  general  observations  and  comments  made  upon  that 
procedure  may  be  considered  to  apply  to  this. 


684  OPERATIVE    SURGERY. 

The  medio-tarsal  joint  having  been  defined,  two  wedge- 
shaped  pieces  of  skin  are  removed — one  from  the  outer,  and 
the  other  from  the  inner  side  of  the  foot.  The  apex  of  each 
cutaneous  Avedge  is  on  the  plantar  surface,  while  the  base  is 
on  the  dorsum,  and  the  size  of  the  bared  area  will  depend 
upon  the  size  of  the  bony  wedge  to  be  removed. 

The  soft  parts  are  cleared  from  the  dorsum,  and  the  wedge 
is  cut  out  with  the  saw  or  chisel  with  the  same  precautions 
and  in  the  same  manner  as  have  been  already  described. 

The  wedge  may  be  extracted  in  one  piece  in  the  form  of  a 
bony  key-stone. 

The  after-treatment  of  the  case  is  the  same  as  has  been 
aheady  detailed,  and  the  results  of  the  few  operations  of  this 
kind  which  have  been  performed  are  included  in  the  remarks 
that  precede  this  section. 

Comment. — In  the  place  of  the  cutaneous  wedges,  straight 
or  T-shaped  incisions  may  be  employed.  The  bones  are  best 
cleared  with  the  rugine,  and  the  chisel  is  decidedly  to  be 
preferred  to  the  saw. 

OPERATION   FOR   CONFIRMED   FLAT-FOOT. 

The  treatment  of  extreme  flat-foot  by  the  excision  of  a 
wedge  of  bone  was  introduced  by  Mr.  Golding  Bird  in  1878. 
(See  paper  in  Lancet,  April  6th,  1889.)  The  wedge  was  taken 
from  the  inner  side  of  the  foot,  and  was  composed  either  of 
the  scaphoid  alone,  or  of  the  scaphoid  together  with  the  head 
of  the  astragalus.  Dr.  Ogston  (Trans.  Med.  Soc,  1884)  excised 
the  astragalo-scaphoid  joint  in  such  a  way  that  the  parts  re- 
moved were  wedge-shaped.  He  then  fixed  the  astragalus  and 
scaphoid  together  with  pegs. 

An  article  by  Mr.  Davy  (Lancet,  April  6th,  1889)  may  be 
consulted. 

The  actual  operation  needs  no  detailed  description.  The 
bone  is  exposed  by  a  simple  incision,  and  the  parts  to  be  re- 
moved are  bared  with  a  rugine.  The  wedge  is  cut  out  vnth  a 
chisel  and  mallet.  No  tourniquet  is  required.  The  foot  is 
adjusted  upon  a  suitable  splint  after  the  operation,  and  is 
treated  as  a  compound  fracture.  There  is  no  need  to  fix  the 
bones  together  by  pegs  or  sutures. 


585 


CHAPTER    VII. 

Operative  Treatment  of  Ununited  Fracture. 

Without  entering  into  the  general  question  of  the  in- 
dications for  interference  in  cases  of  ununited  fracture,  it  is 
necessary  to  point  out  that  delayed  union  of  broken  bones  is 
not  uncommon ;  that  so-called  non-union  depends  upon  many 
conditions,  some  constitutional,  some  local ;  and  that  often 
in  cases  which  have  apparently  become  hopeless  much  can 
be  done  by  general  treatment  and  by  simple  local  measures 
which  are  short  of  operation. 

1.  ununited  fracture  of  long  bones. 

In  dealing  with  ununited  fractures  of  such  bones  as  the 
femur,  the  humerus,  the  tibia,  and  the  radius,  the  operative 
measure  which  appears  to  me  to  be  the  best,  the  simplest,  and 
the  most  complete  consists  in  resecting  the  ends  of  the 
broken  bone,  and  then  retaining  them  in  accurate  apposition 
by  means  of  splints.  Of  the  different  measures  of  which  I 
have  myself  made  use,  none  has  given  such  satisfactory  results 
as  has  this  simple  procedure. 

Certain  of  the  modes  of  treatment  advised  have  little 
to  recommend  them.  Among  such  must  be  named  the 
passing  of  a  large  tenotome  between  the  fragments,  the  intro- 
duction of  a  seton,  the  msertion  of  gilt  steel  needles  into  the 
bone,  or  the  driving-in  of  a  number  of  ivory  pegs. 

These  timid  and  half-hearted  measures  were  possibly 
justified  in  the  days  which  preceded  the  introduction  of  anti- 
septic methods  in  the  treatment  of  wounds.  They  are  feeble 
measures,  which  are  blindly  administered,  and  which  appear 
to  trust  more  to  good-fortune  than  to  sound  science. 

At  the  present  day — when  the  making  of  a  large  wound 
is  (within  reasonable  limits)  not  much  more  serious  than  the 
making  of  a  small  one — these  imperfect  operations  have  little 
reason  for  their  existence. 


586  OPERATIVE    SURGERY. 

The  introduction  of  a  seton  is  a  distinctly  dangerous  and 
reckless  measure ;  the  passage  of  a  tenotome  may  not  be 
dangerous,  but  it  is  purposeless,  and  has  every  prospect  of 
being  futile. 

If  the  bone  has  to  be  exposed  in  order  that  it  may  be 
drilled  and  stimulated  b}^  ivory  pegs,  it  is  a  question — when 
once  the  deep  wound  has  been  made — whether  the  best 
possible  procedure  is  being  carried  out. 

If  a  considerable  mass  of  muscular  tissue  intervenes 
between  the  fragments,  the  pegs  wiU  do  Uttle  good,  and  the 
risks  of  the  wound  will  have  been  incurred  for  nothing:. 

After  the  resection  operation,  on  the  other  hand,  the  ends 
of  the  broken  bone,  freshened  and  freed  of  all  intervening 
tissue,  are  brought  into  actual  and  close  contact,  and  may  be 
said  to  be  placed  in  the  best  condition  for  uniting.  If  the 
surgeon  be  of  opinion  that  the  formation  of  new  bone  will  be 
stimulated  by  the  introduction  of  ivory  pegs,  this  measure 
may  be  adopted  as  an  additional  feature  of  the  operation. 

The  question  of  wiring  the  fragments  will  be  considered  in 
a  separate  section. 

The  Operation  by  Resecting  the  Ends  of  the  Bone. 

Before  undertaking  this  operation,  the  surgeon  should 
understand  that  its  success  depends  more  upon  the  com- 
pleteness of  the  arrangements  that  are  made  for  keeping 
the  bones  in  position  after  the  operation  than  upon  the  opera- 
tion itself,  provided  the  latter  be  carried  out  with  due 
care.  The  operation  involves  the  making  of  a  compound 
fracture,  the  limb  is  at  the  time  flail-like  and  distorted,  the 
muscles  are  shortened,  the  fragments  are  very  possibly  dis- 
placed. 

In  these  circumstances  it  is  necessary  that  the  most 
efficient  form  of  splint  should  have  been  prepared,  and  that 
all  arrangements  should  have  been  made  for  fixing  the  limb 
and  maintaining  such  extension  as  may  be  necessary. 

In  deahng  with  a  fracture  of  the  femur  in  an  adult,  it  is 
well  that  the  operation  be  performed  as  the  patient  lies  upon 
the  bed  he  will  occupy  throughout  the  whole  treatment. 
Much  moving  of  the  patient  after  the  operation  is  very  un- 
desnable,  and  a  long  thigh  splint  with  extension  apparatus 
cannot  be  conveniently  applied  upon  the  operation-table. 


OPERATIONS  FOR   UNUNITED  FRACTURE.  587 

Care  in  the  adjusting  of  the  fragments,  and  infinite  and 
continued  care  in  the  after-treatment,  are  the  main  elements 
of  success  in  the  present  class  of  case. 

The  principal  features  of  the  operation  are  the  following : — 

1.  The  strictest  antiseptic  measures  must  be  observed. 
It  is  essential  that  the  wound  should  heal  without  suppura- 
tion. 

2.  The  incision  must  be  fifee.  In  many  instances  the 
wound  must  be  very  extensive.  A  small  incision  may  greatly 
complicate  the  operation,  may  prevent  the  full  exposure  of  the 
bones,  and  may  lead  to  undue  contusion  and  laceration  of  the 
soft  parts.  The  surgeon  is  likely  to  err  in  the  chrection  of 
making  the  wound  too  small  rather  than  too  large. 

3.  The  wound  should  be  in  the  long  axis  of  the  limb  as 
a  rule,  and  should  be  so  placed  as  to  reach  the  bone  by  the 
shortest  route  and  with  the  least  damage  to  the  soft  parts — 
the  nerves  and  the  blood-vessels  of  the  region. 

4.  The  bones  must  be  well  exposed  and  cleared  of  the 
fibrous  and  cicatricial  tissue  wliich  will  probably  surround 
them.  This  tissue  need  not  be  removed,  but  the  bones  must 
be  well  freed  of  it. 

5.  The  free  end  of  each  fragment  should  be  made  to  pro- 
ject in  turn  through  the  wound.  To  effect  this  the  hmb  will 
probably  require  to  be  bent  at  an  acute  angle  at  the  seat  of 
fi-acture,  large  and  strong  retractors  will  be  required,  and  the 
help  of  able  assistants. 

6.  Each  bone-end  should  be  bared  of  its  periosteum, 
which  is  turned  back  by  means  of  the  rugine  with  as  httle 
disturbance  of  its  connections  with  the  surrounding  soft  parts 
as  is  possible.  It  is  only  necessary  that  the  actual  fi-ee  end 
of  the  bone  be  so  laid  bare. 

7.  With  a  fine  and  sharp  chisel  the  operator  should  then 
proceed  to  remove  a  thin  lamella  from  the  end  of  the  bone, 
so  that  the  fresh  cancellous  tissue  is  ex2)osed  over  the  entire 
section  of  the .  shaft.  IS  o  more  need  be  removed  than  is 
necessary  to  expose  a  surface  of  Hving  vascular  and  active 
bone.  Both  fragments  are  to  be  treated  in  the  same  way. 
The  manner  in  which  the  bone  is  cut  is  of  great  importance. 
The  chisel  should  be  so  employed  that  the  two  raw  surfaces 
can  lie  in  contact,  and  can,  if  possible,  overlap. 


588  OPERATIVE    SURGERY. 

Wliile  there  is  applied  to  the  hmb  the  fullest  amount  of 
extension  that  an  assistant  can  exercise,  the  surgeon  should 
ascertain  what  position  the  fragments  will  occupy  when  the 
limb  is  finally  adjusted  upon  the  splints  he  has  prepared ;  and 
he  should,  if  necessary,  re-apply  the  chisel  until  the  two  frag- 
ments fit  one  another,  and  are  made  to  He  easily  in  contact 
when  the  deformity  has  been  corrected. 

Mere  sawing-ofF  of  the  ends  of  the  bones  is  not  sufiicient, 
nor  is  the  mere  baring  of  the  broken  extremities  all  that  is 
required.  The  bones  must  be  fashioned,  and  be  so  moulded 
with  the  chisel  that  they  maybe  brought  into  proper  contact. 

During  the  use  of  the  chisel  every  care  must  be  taken  by 
means  of  spatulas  and  retractors,  held  by  watchful  assistants, 
to  protect  the  soft  parts.  I  have  found  it  convenient  to  steady 
the  Hmb  against  an  iron  block  covered  with  a  carbolised  towel 
during  the  time  the  chisel  is  being  used, 

8.  The  wound  cavity  should  then  be  well  flushed  out  with 
a  1-50  carboHc  solution,  directed  into  its  depths  by  a  suitable 
irrigator.  Sutures  are  applied,  but  the  close  approximation  of 
the  margins  of  the  skin  wound  is  not  desirable.  I  have  never 
employed  a  drainage-tube  in  these  cases.  The  use  of  the 
elastic  tourniquet  is  to  be  avoided  whenever  possible. 

The  best  dressing  for  the  wound  is  a  large  sponge,  or  a 
pad  of  TiUmann's  dressing,  well  dusted  with  iodoform. 

The  limb  must  finally  be  weH  and  carefuUy  secured  upon 
a  splint,  and  fixed  in  the  best  possible  position.  It  may  be 
necessary  to  divide  a  tendon  now  and  then,  or  sever  rigid 
bands  of  cicatricial  tissue. 

In  neglected  fractures  of  the  thigh,  in  which  non-union 
has  foUowed,  I  have  kept  the  patient  in  bed  for  a  week  or  so 
before  the  operation,  and  have  applied  extension  during  the 
whole  of  that  time,  in  order  to  overcome  the  shortening 
produced  by  contracted  muscles  and  to  bring  the  limb  into  a 
good  position. 

This  preliminary  measure  allows  the  swelling  which  often 
surrounds  the  seat  of  fracture  to  subside,  and  enables  the 
surgeon  to  make  trial  of  the  splint  he  proposes  to  employ  after 
the  operation. 

The  after-treatment  of  these  cases  differs  in  no  way  from 
that  of  compound  fracture. 


OFERATIONS  FUR    UNUNITED   FRACTURE.  589 

The  Operation  by  Wiring  the  Fragments. 

So  far  as  the  long  bones  of  the  extremities  are  concerned,  I 
think  that  this  measure  may  very  well  be  dispensed  with. 

I  made  use  of  it  at  one  time,  but  have  had  good  reasons 
for  abandonmg  it. 

In  the  first  place,  the  wire  can  play  but  a  feeble  part  in 
maintaining  the  fragments  in  position. 

It  is  not  consistent  with  simple  mechanical  principles  to 
assume  that  a  single  loop  of  soft  wire  can  have  great  etiect  in 
keepmg  together  the  broken  ends  of  so  huge  a  bone  as  the 
femur,  especially  when  the  thigh  is  that  of  a  well-developed 
adult.  The  boring  of  the  bones  and  the  passing  of  the  wire 
are  often  very  difficult  and  tedious  steps  in  the  operation, 
and  may  greatly  extend  the  length  of  the  operation.  Much 
damage  has  been  done  to  the  soft  parts  in  this  stage  of  the 
proceeding. 

When  the  wire  is  being  twisted,  the  bones  may  appear  to 
be  in  good  position  ;  but  when  the  splint  is  apphed,  or  the 
attitude  of  the  limb  altered,  the  wire  may  be  found  to  have 
but  httle  hold  upon  the  fragments. 

The  wire  may  be  so  applied  as  to  actually  prevent  the  best 
possible  adjustment  of  the  fragments. 

It  is  true  that  the  loop  may  be  retained  indefinitely  with- 
out the  patient  being  conscious  of  its  presence  in  the  limb  ;  on 
the  other  hand,  it  has  caused  much  irritation,  has  induced 
intense  neuralgic  pain,  has  apparently  lad  to  suppuration  and 
to  a  limited  necrosis  of  the  end  of  the  bone. 

In  the  case  of  a  superficial  bone,  such  as  the  tibia,  the  wire 
loop  may  cause  ulceration  of  the  skin,  and  I  had  on  one 
occasion  to  remove  such  a  wire  on  this  account  many  months 
after  its  introduction. 

It  is  said  that  the  wire  excites  the  growth  of  new  bone ; 
but  if  it  does,  it  appears  to  effect  its  end  at  a  great  cost. 

The  removal  of  the  wire  after  a  period  of  six  or  eight 
weeks  is  often  a  matter  of  the  greatest  difficulty,  especially 
when  the  wound  has  soundly  healed.  A  large  incision  may  be 
required,  much  bruising  of  the  soft  parts  may  be  involved, 
and  at  the  end  the  loop  often  breaks,  and  a  piece  of  the  wire 
has  to  be  abandoned  in  the  depths  of  the  limb. 

If  the  ends  of  the  wire  be  allowed  to  project  through  the 


590  OPERATIVE    SUBGEBY. 

wound,  an  unnecessary  complication  of  the  operation  is 
involved,  and  the  wire  acts  the  part  of  a  seton. 

On  the  other  hand,  if  care  be  taken  to  correct  the  shorten- 
ing so  far  as  possible  before  the  operation,  if  every  measure  be 
observed  which  will  improve  the  local  condition  of  the  limb, 
and  if  the  bone-ends  be  brought  well  together  during  the 
operation,  an  apparatus  will  keep  the  fragments  in  position, 
provided  the  surgeon  is  careful  in  the  selection  of  the 
apphance,  and  still  more  careful  in  the  details  of  the  after- 
treatment. 

It  is  probable  that  in  the  case  of  both  the  humerus  and 
the  femur  a  considerable  degree  of  extension  may  have  to  be 
maintained,  but  the  use  of  the  wire  would  not  mal^e  that 
necessity  the  less. 

I  have  operated  by  the  resection  method  above  described 
upon  ununited  fractures  of  the  humerus,  femur,  tibia,  and 
radius,  and  have  obtained  better  results  by  that  means  than 
ever  attended  the  earlier  operations  in  which  I  wired  the  frag- 
ments together. 

As  a  practical  measure  the  wire  is  a  delusion  and  a  snare  ; 
so  far,  certainly,  as  the  long  bones  are  concerned. 

2.   UNUNITED    FRACTURE   OF   SHORT   BONES. 

The  bones  considered  under  this  heading  are  the  patella 
and  the  olecranon. 

The  Patella. — It  is  assumed  that  such  operations  as  are 
here  described  are  applicable  to  cases  of  ununited  fracture,  cases 
in  which  treatment  has  been  ineffective,  and  in  which  con- 
siderable impairment  of  the  use  of  the  limb  has  resulted.  It 
must  be  assumed  also  that  the  question  of  wearing  an  instru- 
ment has  been  considered  as  an  alternative  to  operative 
interference,  and  that  the  gravity  of  any  measure  which 
involves  the  opening  of  the  knee-joint  has  been  discussed. 

It  would  appear  that  the  treatment  of  recent  simple 
fi'actures  of  the  patella,  by  opening  the  knee-joint  and  wiring 
the  fragments  together,  has  not  come  into  general  use  among 
surgeons.  Indeed,  it  must  be  confessed  that  in  the  great 
majority  of  cases  a  very  satisfactory  degree  of  success  attends 
the  ordinary  and  simpler  modes  of  dealing  with  the  fracture. 

In   cases   of  compound   and   comminuted    fractures    tlie 


OPERATIONS  FOR   UNUNITED  FRAGTLRE.  591 

question  of  wiring  fragments  together  in  the  primary  treat- 
ment of  the  lesion  may  be  considered  in  certain  instances. 

1.  The  Wiring  of  the  Fragments. — This  operation  was  in- 
troduced by  Sir  Joseph  Lister  in  1883,  and  is  carried  out,  it  is 
needless  to  say,  under  the  most  careful  antiseptic  precautions. 

The  knee  being  extended,  a  vertical  incision  is  made  along 
the  front  of  the  knee-joint  over  the  centre  of  the  patellar  frag- 
ments. This  median  cut  may  commence  one  inch  above  the 
upper  fragment,  and  end  one  inch  below  the  lower. 

The  integuments  having  been  separated  by  retractors,  the 
fragments  are  exposed,  and  their  fractured  surfaces  are  cleared 
of  the  fibrous  tissue  and  the  tliickened  synovial  membrane 
which  will  cover  them. 

These  surfaces,  when  freed,  are  then  freshened  by  remov- 
ing a  thin  slice  of  the  bone  with  a  fine,  narrow  chisel. 

In  eftecting  this  each  fragment  should  be  steadied  by 
means  of  lion  forceps,  the  blades  of  which  are  without  teeth. 
A  small  piece  of  sponge  should  be  pressed  beneath  the  frag- 
ment to  prevent  blood  from  running  down  into  the  knee-joint. 

The  lower  fragment,  which  is  usually  also  the  smaller,  is 
the  less  easy  to  deal  with  of  the  two. 

The  bones  are  now  drilled  in  the  median  line  with  a 
carpenter's  bradawl.  The  drill-hole  runs  obliquely  from  the 
upper  or  lower  attached  surface  of  the  bone  (as  the  case  might 
be)  to  the  deeper  layers  of  the  bone  which  are  next  to  the 
cartilage,  and  which  are  exposed  on  the  newly-freshened 
surface  (Fig.  161). 

It  is  important  that  the  drill-holes  should  be  both  pre- 
cisely in  the  median  plane,  or  the  fr-agments  will  be  tilted 
when  the  bone  is  tightened. 

Pure  silver  wire  one-sixteenth  of  an  inch  thick  is  now  intro- 
duced, and,  after  the  sponges  have  been  removed  and  the  joint 
washed  out,  the  fragments  are  brought  together  and  the  ends 
of  the  wire  secured  by  means  of  one  complete  turn.  If  the 
wire  has  to  be  removed,  the  direction  of  the  twist  should  be 
noted. 

Those  who  advise  that  the  wire  be  retained,  cut  the  ends 
short,  and,  twisting  the  stump  of  wire  laterally,  hammer  it  flat 
upon  the  bone  (Fig.  161). 

If  necessary,  the  knee-joint  may  be  drained  by  means  of  a 


592 


OPERATIVE   SURGERY. 


The  fragments  cut  square  and  the  wire  in  position. 


The  wire  knot  hammered  flat. 


Fragments  in  apposition. 

Fig.  161.— WIRING  OF  THE  FEAGMENTS  OF  THE  PATELLA 

AFTEE  FRACTLTtE.      {Barker.) 


small  tube  or  a  strand  of  horse-hair  passed  through  the 
posterior  part  of  the  capsule  of  the  joint.  Such  a  drain  will 
probably  be  removed  at  the  end  of  twenty-four  hours. 

The  hmb  is  adjusted  upon  a  straight  back-splint,  the  skin- 
wound  is  closed  with  sutures  at  the  last  moment,  and  the 

after-treatment  of 
the  case  is  simply 
that  of  fracture  of 
the  patella. 

Gomment.  — 
The  transverse  in- 
cision advised  by 
some  writers  has 
httle  to  recom- 
mend it,  especially 
when  there  is 
much  separation 
of  the  fragments. 
The  freshen- 
ing of  the  bony 
surfaces  with  a 
saw  is  a  proceeding  that  is  to  be  condemned. 

There  is  often  considerable  difficulty  in  bringing  the 
fragments  into  close  contact,  and  some  partial  division  of  the 
rectus  muscle  may  be  necessary  before  this  end  can  be 
attained. 

When  the  lower  fragment  is  of  very  small  size,  the  diffi- 
culties of  the  operation  are  increased. 

2.  The  Use  of  Malgaigne's  Hooks. — I  have  already  men- 
tioned certain  objections  which  appear  to  me  to  apply  to  the 
wiring  of  the  fragments  in  dealing  with  ununited  fractures  of 
the  long  bones. 

In  the  operation  just  described  the  wire  has  been  left  in 
situ  in  a  great  many  instances,  has  given  rise  to  no  trouble, 
and  has  led  to  most  excellent  results.  In  a  few  cases,  how- 
ever, trouble  has  supervened.  The  foreign  body  has  set  u]) 
irritation,  has  caused  pain,  has  prevented  kneeHng,  has  induced 
ulceration  of  the  skin,  and  finally  has  led  to  caries  of  the  bone 
and  suppuration  of  the  knee-joint.  (See  cases  cited  by  Jacob- 
son,  "  Operations  of  Surgery,"  i)ago  1030.  et  aeq.) 


OPERATIONS  FOB   UNUNITED  FRACTURE.  593 

The  removal  of  the  wire  at  the  end  of  six  or  eight  weeks 
is  attended  with  difficulty,  involves  the  opening  up  of  the 
wound,  and  the  attempt  has  often  resulted  in  the  removal  of 
a  portion  of  the  wire  only. 

The  following  method,  which  I  have  carried  out  with  very 
satisfactory  results  in  several  instances,  appears  to  avoid 
certain  of  the  objections  which  may  be  urged  against  wiring  :  — 

The  first  part  of  the  operation  is  conducted  precise^  in 
the  manner  already  described  ;  the  fragments  are  exposed  and 
their  surfaces  are  freshened,  but,  instead  of  drilling  the  bones 
and  bringing  them  together  with  wire,  they  are  approximated 
and  held  in  position  by  a  pair  of  modified  Malgaigne's  hooks. 
{See  paper  by  the  author,  Brit.  Med.  Journ.,  July  24,  1886.) 

The  points  of  the  hooks  are  inserted  on  each  side  of  the 
median  line,  are  driven  through  the  uninjured  skin,  and  are 
forced  well  into  the  bone  near  its  attached  margin  (upper  or 
lower  border,  according  to  the  fragment  dealt  with).  As  the 
instrument  is  in  two  separate  parts,  the  hooks  are  at  first  fixed 
into  the  fragments  independently,  and  the  whole  apparatus  is 
made  one  when  the  two  hook-carrying  plates  are  brought 
together. 

The  plates  are  now  screwed  together,  and  if  the  bones 
cannot  be  brought  close  to  one  another  they  may  be  approxi- 
mated as  nearly  as  is  possible,  and  the  screw  tightened  daily 
until  they  are  in  close  contact.  In  exceptional  cases  it  may 
be  necessary  to  divide  some  fibres  of  the  rectus  muscle. 

In  most  instances  no  drain  is  required.  The  limb  is 
secured  to  a  straight  back-splint,  and  placed  upon  an  inclinetl 
plane.  The  wound  is  entirely  closed  by  sutures,  and  it  and 
the  apertures  formed  by  the  hooks  are  buried  in  iodoform. 

The  general  management  of  the  hooks  is  discussed  in  the 
paper  already  alluded  to. 

The  hooks  should  be  retained  for  some  six  weeks. 

Although  I  have  employed  this  instrument  in  a  large 
number  of  cases,  arid  in  patients  of  various  conditions,  I  have 
never  had  suppuration  follow,  and  in  no  instances  has  there 
been  any  substantial  rise  of  temperature.  The  removal  of 
the  hooks  can  be  effected  with  the  greatest  ease. 

I  would  venture  to  draw  attention  to  the  following  points 
which  appear  to  me  to  be  in  favour  of  this  method  : — 


5W  OPERATIVE    SURGERY. 

The  operation  is  easy  and  simple,  and  tlie  apparatus  is 
■"^ell  exposed  to  view. 

The  fragments  are  held  together  by  liooks,  which  are 
placed  laterally  to  the  median  line,  and  effect  a  more  perfect 
and  more  certain  approximation  of  the  bones  than  does  a 
single  median  wire. 

If  the  bones  are  not  to  be  brought  together  at  once,  they 
can  be  approximated  by  a  more  gradual  process,  viz.,  by 
tightening  the  screw  every  day  for  the  first  few  days.  (When 
once  the  wire  is  fixed,  it  must  remain.) 

The  points  of  metal  penetrate  only  the  surface  layers  of 
the  bone,  and  do  not — Uke  the  wire— involve  a  seton-hke 
passage  through  the  cancellous  tissue. 

The  removal  of  the  hooks  is  very  easy.  (The  removal  of 
the  wire  is  often  difficult.) 

After  the  first  few  hours  of  the  first  day  the  hooks  cause 
no  pain. 

The  Olecranon. 

The  operations  performed  upon  this  bone  are  carried  out 
in  similar  circumstances  to  those  briefly  indicated  in  deal- 
ing with  ununited  fracture  of  the  patella. 

It  is  well  to  operate  before  the  triceps  has  become  greatly 
atrophied  and  shrunken. 

The  method  of  wiring  the  fragments  is  identical  with  that 
above  described,  and  is  open  to  the  same  criticism. 

A  vertical  incision  is  made  over  the  back  of  the  joint. 
The  fi-agment  is  exposed,  is  drawn  down,  is  freed  so  far  as 
is  possible  from  any  morbid  attachments,  and  is  brought  well 
into  view  by  means  of  retractors.  The  surfaces  are  freshened, 
in  the  manner  already  described,  by  a  fine  chisel. 

Holes  are  drilled  obliquely  through  the  bones,  and  pure 
silver  wire  one  twenty-fifth  of  an  inch  in  thickness  is  passed 
through  and  secured  by  one  complete  turn. 

Before  the  bones  arc  approximated  a  straight  splint  should 
be  adjusted  to  the  palmar  side  of  the  lifnb,  so  as  to  fix  the 
elbow  in  the  position  of  extension. 

The  wire  is  either  cut  short  and  the  stump  hammered 
into  the  bone,  or  its  ends  are  left  long  and  the  loop  is 
removed  at  the  termination  of  six  or  eight  weeks. 


595 


CHAPTER    VIII. 
Excision  of  Joints  and  Bones. 

general  considerations. 

By  the  term  "  excision  of  a  joint "  is  implied  the  removal  of 
the  articular  extremities  of  the  bones  entering  into  the  forma- 
tion of  the  joint,  together,  necessarily,  with  the  cartilage  and 
synovial  membrane,  the  procedure  being  carried  out  with  the 
least  possible  amount  of  injury  to  the  surrounding  soft  parts. 

This  definition,  while  it  applies  precisely  to  the  usual 
excisions  of  the  knee  and  elbow,  is  allowed  also  to  include 
the  usual  excisions  of  the  hip  and  shoulder  in  which  only  the 
articular  extremity  of  the  long  bone  forming  the  joint  is 
removed. 

By  excising  a  joint  it  is  often  possible  to  preserve  a  limb 
which,  but  for  this  operation,  would  be  subjected  to  amputation 

The  excision  of  a  bone  may  apply  either  to  the  complete* 
removal  of  a  bone  together  with  its  articular  extremity,  e.g., 
the  inferior  maxilla ;  or  to  the  removal  of  a  portion  of  a  bone, 
e.g.,  the  diaphysis  of  the  humerus,  or  the  acromial  end  of  the 
clavicle. 

History  of  Excision  Operations. — In  the  works  of  the 
older  writers,  from  Hippocrates  downwards,  the  removal  of 
bone  is  advised  in  certain  general  terms  and  in  certain 
conditions.  Under  the  influence  of  this  advice  it  would 
appear  that  am  ng  ancient  surgical  operations  must  be  placed 
the  removal  of  sequestra  and  the  sawing-off  of  the  irreducible 
ends  of  bones  that  have  been  exposed  in  compound  fracture 
or  compound  dislocation. 

The  excision  of  a  joint  as  a  definite  surgical  measure  is, 
however,  quite  a  modern  operation,  and  dates  from  the  latter 
end  of  the  last  century. 

With  the  invention  and  introduction  of  the  operation  two 
names  are  conspicuously  associated — Park,  of  Liverpool ;  and 


596  OPERATIVE    SURGERY. 

Moreau,  of  Bar-siir-Ornain.      The  early  work   of  these    two 
surgeons  appears  to  have  been  independent  of  one  another. 

Park  performed  excision  of  the  knee  on  July  2,  1781, 
for  chronic  joint-disease.  The  patient  was  a  sailor  aged 
thirty-three,  and  he  made  a  perfect  recovery  (Park's  letter 
to  Mr.  Percival  Pott,  September  18,  1782). 

Moreau  carried  out  an  excision  of  the  ankle  on  August 
13,  1782  ("  Essai  sur  I'Emploi  de  la  Resection  des  Os,"  by 
Moreau  the  younger,  Paris,  1803),  and  performed  excision  of 
the  shoulder  in  1786,  and  excision  of  the  elbow  in  1794. 

Prior  to  the  operations  of  Park  and  Moreau  certain 
procedures  of  a  less  definite  and  deliberate  character  had 
been  carried  out.  Thus,  Fellvin  of  Norwich  had  excised  the 
k' :ee  for  disease  in  1762  (the  operation  being  recorded  in  one 
of  Park's  letters).  Bent,  of  Newcastle,  performed  excision  of 
the  shoulder  in  October,  1771  (Philos.  Trans.,  1774),  and  Orred 
repeated  the  procedure  in  1778  {Philos.  Trans.,  1779). 

The  first  excision  in  modern  times  for  comj)ound  dis- 
location is  ascribed  to  Cooper,  of  Bungay.  The  joint  con- 
cerned was  the  ankle,  and  the  operation  was  performed  some 
years  prior  to  1767.  {See  "  Gooch's  Cases  and  Practical 
Remarks  on  Surgery,"  1767.) 

The  first  excision  of  the  hip  was  performed  in  1818  by 
Anthony  White,  of  the  Westminster  Hospital  {London  Med. 
Gazette,  1832,  page  352).  Vigarous,  of  Montpellier,  advised  ex- 
cision of  joints  in  the  treatment  of  certain  gunshot  injuries 
("  Opuscules,"  1788),  and  Percy  appears  to  have  carried  the 
operation  out  in  1799. 

Cliarles  White,  of  Manchester,  removed  in  1708  a  con- 
siderable portion  of  the  diaphysis  of  the  humerus  ("  Cases  in 
Surgery,  Avith  Remarks,"  London,  1770),  with  the  result  that 
the  deficiency  was  so  made  good  by  new  bone  that  the  case 
attracted  great  attention. 

In  the  Philosopliical  Transductions  iov  1766  is  "an  account 
of  the  extraction  of  three  inches  and  ten  lines  of  the  bone  of 
the  upper  arm,  which  was  followed  by  a  regeneration  of  the 
bony  matter,  with  a  description  of.  a  machine  made  use  of  to 
keep  the  upper  and  lower  pieces  of  the  bone  at  their  proper 
distances,"  by  Prof  Le  Cat,  of  Rouen  :  translated  by  Justa- 
mond. 


EXCISION  OF  JOINTS  AND  BONES.  597 

These  early  operations  were  not  very  extensively  imitated, 
and,  indeed,  the  procedures  of  Park  and  Moreau  were  so 
vigorously  condemned  by  many  that  for  some  years  excisions 
were  but  very  rarely  performed. 

The  development  of  the  operation  was  the  work  of  later 
surgeons.  In  Great  Britain  the  credit  of  placing  excision  of 
the  shoulder  and  of  the  elbow  among  recognised  methods  of 
treatment  must  rest  with  Syme ;  and  a  hke  comment  may  be 
applied  to  Ferguson,  so  far  especially  as  the  knee  and  the  hip- 
joints  were  concerned.  Hancock  brought  excision  of  the 
ankle  into  the  scope  of  modern  surgery,  and  Lister  the  opera- 
tion for  excising  the  wrist. 

The  credit  of  the  subperiosteal  method  must  rest  with 
Oilier,  of  Lyons.  Few  men  have  done  more  for  the  operative 
surgery  of  the  joints  and  bones  than  has  this  surgeon.  His 
elaborate  and  most  admirable  treatise  on  resections  contains 
the  most  complete  account  of  excisions  with  which  literature 
has  been  at  present  provided.  His  researches  into  the  growth 
and  formation  of  bone  and  the  action  of  the  periosteum  are 
well  known,  and  his  classical  work  should  be  consulted  by  all 
who  desire  a  fuller  knowledge  of  the  operations  with  which 
this  chapter  deals. 

The  part  played  by  the  jDeriosteum  in  the  formation  of 
bone  was  first  discussed  by  Duhamel  in  1739-43.  The  matter 
was  further  developed  by  Heine  (1837),  and  Flourens  (1840), 
and  still  later  by  Wagner  (1853).  Textor,  Syme,  Blandin,  and 
Chassaignac  all  made  a  point  of  preserving  the  periosteum  in 
their  resections.  Their  examples,  however,  do  not  appear  t  > 
have  been  extensively  followed,  and  the  precise  subperiosteal 
method  is  due  to  Oilier,  whose  first  monograph  upon  the 
subject  appeared  in  1858. 

Some  further  details  relating  to  the  history  of  these 
operations  are  given  in  the  account  of  each  particular 
procedure. 

The  Instruments  employed. — The  following  is  the  hst 
of  the  instrunients  that  may  be  required  in  an  excision 
operation  :— 

Scalpels.     Bistouries  (blunt  and  sharp  pointed). 
Dissecting  and  artery  forceps.     Pressure  forceps. 
Scissors.     Bone  forceps.     Sequestrum  forceps. 


598  OPERATIVE    SURGERY. 

Probes ;  directors ;  special  directors. 

Excision  knives. 

Ivory  or  metal  spatulse.     Retractors  of  various  kinds. 

Lion  forceps. 

Periosteal  elevators.     Rugines. 

Saws  of  various  kinds. 

Chisels  and  Mallet. 

Bone  gouges.  Sharp  spoons. 
Certain  of  these  instruments  require  a  special  notice. 
7%e  Excision  Knife. — This  knife  should  have  a  large 
handle  and  a  short  but  stout  blade  (Fig.  162).  It  is  an 
instrument  by  means  of  which  the  surgeon  can  give  the  short, 
strong,  clean  and  heavy  cuts  down  to  the  bone  which  are  so 
conspicuous  a  feature  in  excision  operations.  Fig.  162  shows  the 
most  useful  form  of  knife  for  general  purposes.  Fig.  163 
represents  an  excision  knife  with  a  straight  edge,  which  will  be 
found  very  convenient  in  dealing  with  some  irregular  surfaces, 
and  also  in  dividing  the  periosteum. 

The    Periosteal  Elevator  or  Engine. — Man}^   patterns   of 


Fig.    1G2. — EXCISION   KNII'K. 


Fig.   163. — EXCISION    XiMij 


this  instrument  exist.  The  rugine,  or  ddtache-tendon,  is 
employed  to  strip  the  periosteum  from  the  bone. 

The  most  convenient  instruments  are  those  of  Farabeuf, 
Fig.  164  shows  the  straight  rugine,  which  wiU  meet  with  the 
requirements  of  most  operations ;  and  also  the  curved  rugine, 
which  is  admirably  adapted  for  curved  and  irregular  surfaces. 
It  has  likewise  been  used  as  a  conductor  or  director  for  the 
chain -saw. 

Tlie  ordinary  periosteal  elevator  (Fig.  165),  as  it  is  figured 
in  the  catalogues  of  English  makers,  is  a  useful  instrument 


EXCISION  OF  JOINTS  AND  BONES. 


599 


It  is  of  little  service  in  actuall}^  detaching  the  periosteum,  but 
is  useful  in  raising  it  when  it  has  been  detached. 

Retractors. — Retractors   play   a   very    important    part 


in 


excision  operations.  Those 
of  the  ordinary  pattern 
will  suffice.  {See  page 
40.)  The  most  service- 
able are  of  steel  and  are 
rectangular. 

A  useful  retractor  can 
be  made  with  a  long,  thin, 
and  narrow  strip  of  pliable 
metal  {e.g.,  malleable  iron 
plated).  Its  application 
in  a  case  of  excision  of  the 
elbow  is  shown  in  Fig.  187. 

Good  ivory  spatulse  are  of  great  service  to  protect  the  soft 
parts  during  sawing. 

Saw  Directors. — Blandin's  director  of  the  pattern  shown 
in  Fig.  166  is  of  value  in  protecting  the  soft  parts  when  the 


Mff.    164. 


FAitABEUF's     EUGINE3, 
AND   CUEVED. 


Fig.  165. — lan&enbeck's  periosteal  elevatob. 

saw  is  being  aj  phed.     It  is,  indeed,  made  to  act  as  a  director 
for  the  saw. 

It  can  be  employed  also  as  a  guide  in  passing  the  chain- 
saw  around  a  bone. 


Fig.  166. — blandin's  dieectoe  foe  eesections. 


Lion  Forceps. — Of  the  various  forms  of  lion  forceps  or 
bone-holding  forceps,  Farabeuf's  is  perhaps  the  best. 

By  means  of  its  double  axis  it  is  enabled  to  grasp  firmly  a 
bone  of  any  size,  and  will  hold  a  metacarpal  bone  as  steadily 


600  OPERATIVE    SURGERY. 

as  it  will  fix  the  head  of  the  humerus  (Fig.  167).  The 
davier-erigne  shown  in  Fig.  168  is  admirably  adapted  for 
grasping  soft  and  fiiable  bones. 


167. — FAEABEtTF'S  BONE-HOLDING   FOECEPS. 


Saivs. — The  particular  kind  of  saw  employed  must 
depend  upon  the  taste  and  custom  of  the  individual  surgeon. 
The  best  for  most  excision  operations  is  a  simple  straight 
narrow  saw  with  a  movable  back.  In  some  instances,  e.g ., 
in  certain  excisions  for  anchylosis,  a  rat-tail  or  key-hole  saw  is 
needed. 

If  it  be  considered  needful  to  give  a  curved  surface  to  the 


168.— OLIIEE'S  forceps   foe   seizing   cancellous   ok   IKIALLE   BONK 


free  end  of  the  bone,  this  may  best  be  done  by  means  of  a 
slender  Butcher's  saw, 

French  surgeons  are  for  the  most  part  in  favour  of  the 
chain-saw,  but  that  instrument  has  never  held  a  very  pro- 
minent position  with  English  operators. 

The  General  Conditions  of  Excision  Operations. 

The  remarks  in  this  and  the  following  chapters  apply 
especially  to  excisions  of  joints,  but  they  may  be  taken  as 
refeiTing  also,  with  appropriate  modification,  to  resections  of 
bones. 

The  excision  of  a  joint  may  be  j)ractised  for  the  relief 
of  any  of  the  following  conditions  : — Advanced  joint-disease ; 
disease  of  the  articular  ends  of  the  bones ;  injury,  such  as  gun- 
shot wound,  compound  or  unreduced  dislocation ;  anchylosis ; 
and  certain  deformities. 


EXCISION  OF  JOINTS   AND  BONES.  601 

The  great  iiiajority  of  the  cases  of  excision  have  been 
carried  out  for  the  rehef  of  strumous  or  tubercular  disease  of 
the  joint  ("  white  swelHng  ") ;  and  the  chief  discussions  relative 
to  excision,  and  the  main  statistics  that  deal  with  the 
operation,  are  concerned  with  excisions  for  chronic  joint- 
disease. 

In  performing  excision  of  a  joint,  the  following  general 
points  are  to  be  observed  : — 

1.  The  whole  of  the  diseased  tissue  must  be  removed. 

2.  The  amount  of  the  bone  removed  must  be  limited  by 
such  common  surgical  requirements  as  are  necessary  to  ensure 
the  prospect  of  a  useful — or,  at  least,  not  utterly  useless — Hmb. 
It  is  j)ossible  to  remove  so  much  bone  that  although  the 
wound  heals  firmly  and  well,  the  patient  is  left  with  a  flail- 
hke  limb,  which  is  an  actual  encumbrance.  "  Figurez-vous," 
writes  Farabeuf,  "  un  genou  et  meme  un  coude  de  caoutchouc, 
la  jambe  ou  I'avant-bras  oscillant  au  gre  de  la  pesanteur ! " 
The  common  observation  that  "  any  limb  is  better  than  no 
limb  "  is  not  to  be  accepted  entirely. 

3.  The  soft  parts  must  be  as  little  disturbed  as  possible. 
The  surgeon's  object  should  be  to  remove  nothing  but  bared 
bone,  free  of  all  its  periosteum.  Every  care  must  be  taken  to 
preserve  the  connections  of  tendons  and  hgaments,  and  to 
avoid  injury  to  vessels  and  nerves  of  any  magnitude. 

4.  Care  must  be  taken  in  young  subjects  that  the  active 
epiphysis  be  not  destroyed,  lest  a  greatly-shortened  limb 
result — a  matter  of  infinite  consequence  in  the  lower  ex- 
tremity. 

5.  The  bones  must  be  so  divided  as  to  be  adapted  to  the 
purposes  of  the  new  articulation,  or  be  favourable  for  anchy- 
losis in  a  good  position.  In  excising  the  knee-joint,  it  is 
possible  that  one  careless  operator  may  bring  about  a  con- 
dition of  knock-knee  in  the  healed  Hmb,  and  another  a  con- 
dition of  bowed  leg. 

6.  The  after-treatment  must  be  a  matter  of  infinite 
patience  and  infinite  care ;  and  the  selection  of  a  suitable 
apparatus  for  the  fixing  of  the  hmb  is  a  subject  of  consider- 
able moment.  In  the  upper  extremity,  and  in  the  hip  and 
ankle,  a  joint  capable  of  some  degree  of  movement  is  expected 
after  the  excision ;  in  the  knee  anchylosis  is  generally  sought  for. 


602 


OFEBATIVE   SURGERY. 


7.  The  surgeon  must  be  fully  alive  to  the  general  surgical 
aspects  of  the  case,  to  the  condition  of  the  patient,  to  his 
prospects  of  standing  a  long  and  severe  operation,  and  to  his 
capacity  for  exhibiting  vigorous  powers  of  repair.  An  ex- 
cision is  to  some  extent  a  plastic  operation,  and  good  and 
substantial  healing  is  a  necessity. 

It  thus  happens  that  in  the  practice  of  most,  an  excision  is 


Fig.    169. — THE  METHOD  OF  TJSrNG  THE   EUGINE. 

A,  Over  a  level,  and  B,  over  an  unequal  surface.     {Oilier^ 


never  done  in  the  very  young,  nor  in  subjects  over  forty,  and 
this  more  especially  applies  to  excisions  for  disease. 

In  carrying  out  an  operation,  it  is  well  to  avoid  an 
Esmarch's  tourniquet.  Many  excisions  involve  a  consider- 
able expenditure  of  time;  and  to  render  the  limb  bloodless 
during  the  whole  of  that  period  is  most  undesirable.  The 
general  objections  to  the  "  bloodless  method "  have  been 
already  detailed.  These  objections  conspicuously  apply  to 
the  present  class  of  operations. 

The  oozing  that  follows  the  use  of  the  elastic  band  is 
especially  marked  after  these  operations,  and  tends  to  inter- 
fere with  the  dressing  of  the  case,  to  retard  healing,  and  to 
place  difficulties  in  the  way  of  a  rigid  adjustment  of  the 
limb. 

The   skin   incisions  must  be  considered   with  gi*eat  care. 


EXCISION  OF  JOINTS   AND  BONES.  603 

The  more  modern  operations  favour  the  most  simple  form  of 
wound — a  single  straiarht  cut. 

The  measures  adopted  by  some  of  the  earher  operators 
were  very  complex  and  needlessly  extensive. 

The  Open  Method  and  the  Subperiosteal  Method. 

The  excision  of  a  joint  may  be  carried  out  by  either  of 
the  tAvo  methods  just  named. 

T/ie  Open  Method. — In  the  open  method  (the  ^inethode  du 
histouri  of  the  French)  the  bones  are  exposed  through  the 
simplest  and  most  direct  incision ;  the  soft  parts  are  disturbed 
as  httle  as  is  possible  ;  any  tendons  which  may  be  attached  to 
the  bones  to  be  excised  are  not  cut  through,  but  are  peeled 
off  or  separated  from  their  point  of  attachment.  The  liga- 
ments of  the  joint,  or  certain  of  them,  can  hardly  escape  divi- 
sion. 

The  bones  are  protected,  and  are  sawn  off!,  but  no  care 
is  taken  to  separate  and  preserve  the  periosteum  which  is 
attached  to  them. 

The  Subperiosteal  Method. — In  the  subperiosteal  method 
(the  rtiethode  de  la  rugine)  the  articular  ends  of  the  bones  are 
exposed,  probably  through  a  similar  incision  to  that  observed 
in  the  open  method.  The  great  object  of  the  operator,  how- 
ever, is  to  save  the  whole  of  the  periosteum  of  the  involved 
district,  and  at  the  same  time  to  preserve  the  capsular  liga- 
ment intact.  The  process  may  be  illustrated  by  such  a  joint 
as  the  elbow.  The  articular  hgaments  (namely,  the  anterior, 
posterior,  internal  lateral,  and  external  lateral)  form  together 
a  complete  capsule,  which  joins  above  and  below  with  the 
periosteum  of  the  bones  of  the  forearm  and  upper  arm. 

The  osseous  tissue  to  be  removed  is  shelled  out  from  within 
this  investment  of  periosteum  and  ligament.  The  capsule,  and 
the  periosteum  into  which  it  extends  above  and  below,  are 
divided  in  one  vertical  incision.  The  gap  made  is  enlarged ; 
the  bones  are  decorticated ;  they  are  stripped  of  periosteum, 
but  at  the  same  time  the  connections  between  that  membrane 
and  the  capsule  of  the  joint  are  not  disturbed.  The  articular 
ends  when  bared  are  then  protruded  through  the  incision  or 
incisions  made  in  this  capsulo-periosteal  sheath  (la  gaine 
periosteo-capsulaire).  The  term  resection  sous  capsulo-peri- 
ostee,  applied   by  French  surgeons  to  this  method,  serves  to 


604 


OPERATIVE    SUE  GEE  Y. 


emphasise  the  fact  that  the  procedure  consists  of  something 
more  than  the  mere  preservation  of  periosteum  (Fig.  170). 

The  hgaments  of  the  joints  retain  their  original  con- 
nection, and  any  attached  tendons— such  as  that  of  the 
triceps — are  separated  with  the  capsulo-periosteal  sheath,  its 


Fig.    170. — DIAGEAMS   TO   ILLTJSTEATE  THE   SUB-PEKIOSTEAL  METHOD   OF  EESECTION. 

H,  Humerus  ;  U,  Ubia  ;  a,  Anterior  ligament ;  b,  Posterior  ligament ;  c,  Periosteum  ; 
d,  Capsulo-periosteal  sheath  separated  by  the  rugine.  (The  lines  of  the  saw-cuts 
are  shown. ) 


relations  to  the  investing  membrane  of  the  bone  not  being 
disturbed. 

The  advantages  and  disadvantages  of  the  suh-periosteal 
method. — The  advantages  claimed  for  the  sub-periosteal 
method  are  the  following  : — 

(a)  The  periosteum  being  preserved,  new  bone  is  formed 
to  replace  that  which  has  been  removed. 

(6)  The  capsule  of  the  joint  is  preserved,  and  the  con- 
nections of  the  ligaments  are  not  severed;  the  new  articulation 
is  therefore  likely  to  be  all  the  stronger. 

(c)  The  connections  of  the  tendons  with  the  periosteum 
are  not  disturbed,  and  greater  muscular  strength  is  con- 
sequently given  to  tlie  new  joint. 


EXCISION  OF  JOINTS  AND  BONES.  605 

(d)  There  is  niiicli  less  haemorrhage,  the  chief  area  of  the 
operation  being  subperiosteal. 

(e)  Planes  of  connective  tissue  are  not  opened  up,  and  the 
cavity  left  after  the  removal  of  the  bones  is  limited  and 
circumscribed  by  the  capsulo-periosteal  sheath. 

With  regard  to  these  claims,  there  is  no  doubt  but  that, 
in  favourable  circumstances,  a  large  quantity  of  new  bone 
is  produced  to  make  good  that  lost  by  the  operation. 

The  importance  of  the  periosteum  in  this  connection 
would  appear  to  be  paramount,  although  some  recent  writers 
have  adduced  evidence  in  support  of  the  view  that  the  bone- 
forming  functions  of  the  periosteum  have  been  over-estimated. 

In  the  most  successful  cases  it  cannot  be  said  that  the 
articular  ends  of  the  bone  are  reproduced,  and  that  the  new 
jomt  is  a  reproduction  of  the  old.  New  bone  is  formed,  and 
fills  the  periosteal  cavity,  and  by  the  periosteum  it  is  limited 
and  moulded  (Fig.  171).  The  ncAv  bone  is,  as  it  were,  poured 
into  a  mould.  The  amount  produced  varies.  In  some  in- 
stances no  new  bone  is  produced  even  when  a  considerable 
portion  of  the  periosteum  is  saved  ;  in  other  cases  an  excessive 
amount  is  found  to  have  been  formed ;  in  a  few  examples  the 
reproduction  of  the  details  of  the  lost  bones  has  been  precise 
and  remarkable.  In  all  circumstances  it  would  appear  that 
the  new  bone  is  a  little  unstable,  and  that  it  is  liable  to 
undergo  a  certain  but  varying  amount  of  re-absorption. 

The  value  of  the  new  bone  so  produced  cannot  be  over- 
estimated when  the  results  of  operations  come  to  be  compared, 
and  the  main  advantage  of  the  subperiosteal  method  may  be 
considered  to  be  based  upon  this  feature. 

The  preservation  of  ligaments  and  tendinous  connections 
is  another  advantage  of  this  method — an  advantage  that  is 
substantial  and  definite. 

The  disadvantages  of  the  subperiosteal  operation  cannot, 
on  the  other  hand,  be  overlooked. 

The  measure  is  admirable  in  theory,  but  it  does  not  always 
assume  so  immaculate  a  position  in  practice. 

In  the  first  place,  the  detachment  of  the  periosteum  is 
difficult  and  tedious.  The  student  who  attempts  a  sub- 
periosteal resection  for  the  first  time  upon  the  cadaver  will 
find,  especially  if  the  subject  be  old,  that  the  periosteum  is  not 


606 


OPERATIVE    SUBGEBY. 


so  substantial  a  membrane  as  it  is  sometimes  represented,  and 
that  its  separation  is  a  matter  of  considerable  mechanical 
difficulty.  When  the  complex  surface  of  the  lower  end  of 
the  humerus,  for  example,  is  dealt  \nth,  it  is  not  improbable 
that   the   rus^ine   will  detach   the   membrane  in  shreds.     In 

traumatic  cases,  in  adults, 
the  surgeon  will  find  in 
practice  that  the  strict 
carrying  out  of  the  method 
of  Oilier  is  barely  possible. 
The  operator  Avho 
blindly  persists  in  follow- 
ing this  method  will  often 
find  that,  after  much  valu- 
able time  has  been  ex- 
hausted, he  has  bared  the 
bone  of  periosteum,  but 
has  left  that  membrane 
in  shreds  and  holes. 

It  is  not  only  the 
operator's  surgical  faith 
which  suffers  from  the 
tyranny  of  a  method  ;  the 
patient  also  is  troubled, 
and  in  a  more  material 
way. 

In  young  subjects  the 
periosteum  is  thicker,  more 
active,  more  substantial, 
and  more  easily  stripped 
oft*.  It  may  also  be  said 
that  it  is  more  precious, 
and  is  in  more  need  of  being  preserved. 

In  cases  attended  by  chronic  inflammation  the  periosteum 
is  generally  very  easily  detached,  but  in  such  a  condition  it  is 
often  of  doubtful  value.  It  may  be  infiltrated  with  inflam- 
matory material,  may  hinder  the  healing  of  the  wound,  and 
may  even  maintain  suppuration.  But  if  it  lack  these  poten- 
tialities for  evil,  it  may  possess  no  bone-producing  property. 
In  cases  of  excision  performed  for  new  q-roAvth  the  preserva- 


fig.  171. — eestoeation  of  the  elbow-joint 
after  subperiosteal  excision  (anterior 
view). 

A,  Hnmerus  ;  B,  Radius  ;  c,  Ulna ;  D,  Exter- 
nal tuberosity  ;  E,  Internal  tuberosity  ;  f, 
( 'oronoid  process  with  mammillary  forma- 
tions of  bone ;  a,  Level  at  wliich  the  new 
formation  of  bone  is  supposed  to  liave  com- 
menced ;  1,  External  lateral  ligament ;  2, 
Internal  lateral  ligament ;  3,  Annular  liga- 
ment of  radius.     {Oilier.) 


EXCISION  OF  JOINTS  AND  BONES.  607 

tion  of  the  periosteum  will,  in  nearly  every  instance,  be  most 
undesirable. 

In  the  next  place,  the  subperiosteal  operation  involves 
a  considerable  period  of  time  in  the  performance,  and  the 
shock  following  the  procedure  may  be  not  inconsiderable.  In 
this  respect  it  compares  unfavourably  with  an  excision  by 
the  open  method,  where  the  actual  steps  of  the  operation  are 
simple  and  the  process  quick. 

Summary. — It  may  be  said,  in  conclusion,  that  the  sub- 
periosteal operation  is  excellent  in  theory,  but  it  is  only 
excellent  in  practice  in  selected  cases.  Although  it  is  the  pro- 
cedure which  should  be  adopted  w^henever  possible,  it  can 
never  become  a  routine  method  of  performmg  excision.  It 
is,  indeed,  of  somewhat'  limited  appUcation.  A  partial  sub- 
periosteal resection  may  often  be  carried  out  in  instances 
where  the  complete  operation  is  impossible,  and  there  must  be 
few  cases  in  which  it  is  not  desirable  to  take  every  precaution 
to  preserve  the  connections  of  Hgaments  and  the  periosteal 
attachments  of  tendons. 

The  open  method,  practised  as  it  was  in  the  earlier  days  of 
surgery,  when  hgaments  and  tendons  were  divided  without 
scruple,  may  be  safely  regarded  as  a  matter  of  the  past ;  but 
such  a  modification  of  this  method  as  the  subperiosteal  pro- 
cedure suggests  is  of  great  and  wide-extending  value. 

Circumstances  that  Influence  the  Result  of  Excision 
Operations. 

So  far  as  excisions  of  joints  are  concerned,  the  conditions 
that  may  be  considered  under  this  heading  are  ver}' 
numerous,  and  can  only  be  dealt  with  in  outline.  They  con- 
cern not  only  those  general  circumstances  that  influence  the 
healing  of  wounds  and  the  recovery  of  patients  after  operation, 
but  embrace  certain  local  features  that  are  more  or  less 
obvious. 

The  success  of  the  operation  will  depend  upon  the  age  of 
the  patient,  upon  his  condition,  upon  his  powers  of  exhibiting 
repair  from  extensive  wounds,  and  upon  the  general  circum- 
stances that  affect  primary  heahng. 

His  nervous  condition  is  a  matter  of  importance,  as  is  also 
his  capacity  for  submitting  to  a  tedious  and  often  painfid  after- 
treatment.     The  question  of  antisepticism  needs  but  to  be 


<)08  OPERATIVE    SURGE BT. 

mentioned.  So  far  as  the  operation  is  concerned,  much  will 
depend  upon  the  state  of  the  tissues,  upon  the  nature  of  the 
disease,  upon  the  amount  of  bone  removed,  upon  the  complete 
ehmination  of  the  moAid  structures,  and  upon  the  safety  of 
important  tissues  in  the  vicinity  of  the  oi:)eration. 

The  After-treatment. 

Few  operations  can  be  cited  in  which  the  after-treatment 
is  more  important,  and  in  which  it  has  a  greater  influence 
upon  the  success  of  the  case.  However  well  the  excision  may 
have  been  carried  out,  and  however  favourable  the  case  may 
be,  the  whole  complexion  may  be  altered  and  transformed  by 
nesrlect  in  the  after-treatment. 

The  wound  must  be  kept  aseptic,  and  in  general  terms  it 
may  be  said  that  dry  and  infi-equent  dressings  should  be 
mainly  rehed  upon. 

The  sphnt  must  be  selected  with  care,  and  must  be  applied 
with  precision.  The  principal  features  in  the  after-treatment 
are  identical  with  those  attending  the  care  of  compound 
fractures. 

The  position  of  the  limb  must  be  accurately  prescribed. 
If  anchylosis  be  wished  for,  the  bones  must  be  brought  into 
close  contact,  and  must  be  kept  in  very  rigid  relation  with  one 
another. 

If  it  be  intended  that  a  movable  articulation  should 
result,  then  the  approximation  of  the  bones  should  be  less  close. 

No  rule  can  be  given  that  will  render  definite  the  precise 
degree  of  separation  of  parts  that  is  desirable  after  the  opera- 
tion. The  approximation  will  be  less  close  in  adults  than 
in  young  subjects,  and  in  cases  where  much  periosteum  has 
been  preserved  than  in  those  where  much  has  been  lost. 

It  may  be  that  a  week  or  so  will  have  to  elapse  before  the 
surgeon  can  satisfy  himself  that  the  adjustment  of  the  sawn 
ends  of  the  bones  is  the  best  that  can  be  attained. 

In  some  instances,  notably  those  associated  with  existing 
deformity  of  the  joint,  it  may  not  be  wise  to  enforce  the  ideal 
position  at  once,  but  the  limb  will  have  to  be  brought  gradually 
into  the  desired  attitude. 

When  mobility  is  desired,  passive  movements  will  have  to 
bo  undertaken.  These  may  generally  be  commenced  as  soon 
as  the  inflammatory  symptoms  have  subsided,  and  as  soon  as 


EXCISION   OF  JOINTS  AND  BONES.  609 

the  sensitiveness  of  the  part  has  become  less  acute.  In  most 
cases  this  will  be  represented  by  a  period  varying  from  one  to 
three  weeks. 

The  treatment  of  the  general  health,  the  duration  of  the 
treatment  by  apparatus,  and  the  employment  of  massage  and 
electricity  will  depend  upon  general  principles. 

Results. 

OUier's  statistics  deal  with  274  cases  of  excisions  of  joints: 
performed  by  himself  between  the  years  1861  and  1884.  The 
i a  ortahty  of  the  whole  series  is  31  "02  per  cent.,  which  OUier 
d  ivides  in  the  following  manner  : — 

Deaths  from  the  actual  operation       ...  13'13  per  cent. 

Deaths    due  to    a    continuation  of    the    primary 

disease  (tuberculosis)        ...         ...  13-13      „ 

Deaths  from  intercurrent  diseases  ...         ...          ...  i'75       „ 

The  mortality  after  excisions  for  injury  was  51  "8  per  cent., 
and  after  excisions  for  disease  28*4  per  cent. 

The  mortahty  due  to  the  actual  operation  prior  to  the 
employment  of  antiseptic  measures — i.e.,  before  1878 — was 
233  per  cent.,  and  after  that  was  4*8  per  cent. 

MacCormac  gives  the  following  as  the  mortality  following 
individual  resections  for  disease.  The  period  covered  is  from 
1876  to  1885  inclusive,  and  all  the  operations  were  performed 
at  St.  Thomas's  Hospital : — 

Shoulder  ...         ...         ...         ...  10"0  per  cent. 

Elbow 2-4         „ 

Wrist 0-0         „ 

Hip      7-8        „ 

Knee 9-0         „ 

Ankle 7-1         „ 

Otis  gives  the  mortality  after  resections  of  various  kinds 
for  gunshot  injury  as  276  per  cent. 

The  mortality  after  excisions  in  general  is  high  before  five 
years  of  age  and  after  thirty.  The  most  favourable  results  are 
obtained  in  children. 

In  England  these  operations  are  not  very  frequently  per- 
formed. At  the  London  Hospital,  during  the  four  years  ending 
December  31,  1888,  only  thirty  excisions  of  articulations 
were  performed  (twelve  of  the  elbow,  ten  of  the  knee,  four  of 
the  wrist,  and  four  of  the  hip).  Of  this  number  one  patient 
died,  after  excision  of  the  hip,  from  tubercular  meningitis. 


610 


CHAPTER    IX 


Excisions  of  the  Fingers,  Thumb,  and  Metacarpus. 

These  operations  are  but  seldom  required,  and  can  but  very 
rarely  be  carried  out  upon  precise  and  systematic  lines. 

Most   of  the   so-called   excisions   of  bones  consist  of  re- 
movino'  larefe  necrosed  fras^ments,  such  as  that  formed  bv  the 

ungual  phalanx  after  whitlow,  or  as 
may  be  produced  in  the  diaphysis  of 
a  metacarpal  bone. 

Not  a  few  of  the  bone  excisions 
in  this  region  described  in  some  text- 
books could  scarcely  ever  be  appHed 
to  the  living  subject. 

Excisions  of  the  joints  have  been 
carried  out  in  the  treatment  of  sup- 
purative inflammation,  anchylosis, 
deformity,  and  unreduced  dislocation, 
and  have,  with  certain  reservations, 
pro^-ed  moderately  successful. 

Anatomical   2^oints.  —  The   pha- 

Olanges  and  metacarpal  bones  consist 
of  a  shaft  and  of  one  epiphysis. 

In    the    four    inner    metacarpal 

bones  the  epiphysis  is  at  the  distal 

end  of  the  bone,  and  forms  the  head. 

In  the  metacarpal  bone  of  the  thumb 

the    epiphysis   is   at   the   proximal 


8 


Fig.     172. — EPIPHYSES    OF    THE 
THUMB    AND   INDEX   FINGEE. 


and    in    the    phalanges 
extremity  (Fig.  172). 

There  is  usually  a  trace  of  an  epiphysis  in  the  head  of  the 
first  metacarpal  bone  about  the  age  of  seven  years. 

The  epiphyses  commence  to  ossify  about  the  fourth  year, 
and  join  the  shafts  about  the  tAventieth  year. 


EXCISION  OF  PHALANGES.  611 

1.  Terminal  Phalanges. 

The  ungual  plialaiix  may  be  conveniently  excised  through 
a  U-shaped  palmar  incision,  which  will  circumscribe  the  pulp 
of  the  digit.  The  curved  extremity  of  the  U  is  brought  close 
to  the  nail.  The  base  of  the  little  b  »ne  should  be  preserved 
if  possible,  as  it  forms  the  epiphysis  and  gives  attachment  to 
the  flexor  profundus  digitorura. 

2.  Inter-phalangeal  Joints. 

A  single  lateral  incision  is  made  upon  one  or  other  side  of 
the  joint  in  the  long  axis  of  the  phalanx.  If  the  cut  be  placed 
opposite  to  the  centre  of  the  digit — as  regards  its  width  from 
dorsum  to  palm — the  vessels  and  tendons  will  be  avoided 
(Fig.  173,  B). 

The  lateral  ligament  being  divided,  the  bones  are  made 
to  protrude,  are  carefully  cleared  of  soft  parts,  and  are  then  re- 
moved with  a  very  fine  saw.  To  safely  effect  this  section  a 
grooved  curved  director  should  be  introduced  to  receive  the  saw. 

If  two  lateral  incisions  be  employed,  the  operation  is 
rendered  much  easier. 

3.  Metacarpo-phalangeal  Joints. 

Precisely  the  same  method  is  employed  as  in  the  above 
case.  If  a  single  lateral  incision  be  made  use  of,  it  should  be 
placed  externally  in  the  case  of  the  thumb  and  index  finger, 
internally  in  the  case  of  the  little  finger,  and  to  one  or  other 
side  of  the  dorsal  aspect  of  the  joint  when  the  other 
metacarpo-phalangeal  joints  are  concerned  (Fig.  173,  A  and  c). 

4.  Metacarpal  Bone  of  the  Thumb. 

In  this  little  operation  the  subperiosteal  method  should, 
whenever  practicable,  be  very  precisely  carried  out. 

The  hand  is  held  firmly  upon  a  table,  with  the  radial  side 
uppermost. 

An  incision  is  made  along  the  outer  side  of  the  metacarpal 
bone,  and  is  so  placed  as  to  lie  over  the  lateral  border  of  the 
bone  and  to  be  upon  the  anterior  or  palmar  side  of  the 
extensor  tendons.  The  incision  is  carried  in  one  direction 
over  the  metacarpo-phalangeal  joint,  and  in  the  other  over 
the  trapezium  (Fig.  173,  d). 

In  dividing  the  soft  parts,  care  is  taken  to  avoid  the  branch 
from  the  radial  nerve  to  the  outer  side  of  the  thumb. 

The  bone  is  exposed,  and  the  separation  of  the  periosteum 


612 


OrEliATlVE    SURGERY. 


Fig.  173. — A,  Excision  of  metacarpo-phalangeal  joint 
of  index ;  B  B,  Excision  of  iuter-phalangeal  joint  of 
thumb  ;  C,  Excision  of  metacarpo-phalangeal  joint  of 
thumb  ;  D,  Excision  of  first  metacarpal  bone. 


is  commenced  at  the  centre  of  the  shatt.  Small  rugines  are 
required,  the  surgeon  using  at  first  a  straight  one  and 
afterwards  a  curved  mstrument.  The  soft  parts  are  cleared  up 
to  the  head  of  the  bone,  where  the  structures  of  the  joint  are 

separated  and  the 
head  of  the  bone  is 
made  free. 

This  end  — 
quite  stripped — is 
made  to  protrude 
through  the  wound, 
and  is  seized  and 
held  by  Hon  for- 
ceps. 

The  surgeon 
then  proceeds  to 
decorticate  the  rest 
of  the  bone  as  far 
back  as  the  proxi- 
mal joint.  The  muscular  attachments  are  separated  with  the 
periosteum,  and  the  whole  bone  is  removed. 

It  win  be  obvious  that  this  subperiosteal  method  can  onlj'' 
be  carried  out  under  quite  exceptional  circumstances,  and  in 
young  subjects. 

Whether  the  subperiosteal  method  be  pursued  or  not,  the 
steps  of  the  operation  will  be  the  same. 
5.  Metacarpal  Bones  of  the  Fingers. 
An  incision  is  so  made  along  the  dorsal  aspect  of  the 
metacarpal  bone  as  to  avoid  the  extensor  tendons.  The  bone 
is  exposed,  and  the  centre  of  the  shaft  is  well  cleared. 
Around  this  portion  of  the  bone — when  entirely  freed— a 
much-cui-ved  director  is  passed,  and  the  bone  is  divided  by 
means  of  cutting  forceps.  Each  divided  end  can  now  in  turn 
be  seized  with  lion  forceps,  be  freed  of  its  soft  parts,  and  be 
removed.     The  bone  is  therefore  excised  in  two  seii^ments. 

Comments  and  Results. — It  is  certainly  better,  whenever 
possible,  to  excise  the  ungual  phalanx  rather  than  to 
amputate  the  end  of  the  digit. 

Excisions  of  the  inter-phalangeal  joints  have  afforded  very 
satisfactory  results. 


EXCISION  OF  PHALANGES.  613 

Excision  of  the  metacarpo-phalangeal  joint  of  a  finger  is 
not  an  operation  in  favour  of  Avhich  much  can  be  said.  It  is 
apt  to  leave  a  flail-like  finger,  which  is  possibly  an  actual 
source  of  inconvenience. 

In  youn^  subjects  this  operation  should  not  be  performed, 
as  it  involves  the  destruction  of  the  epiphysis  of  both  the 
metacarpal  bone  and  of  the  phalanx. 

Excision  of  the  metacarpo-phalangeal  joint  of  the  thumb 
has,  on  the  other  hand,  been  followed  by  very  excellent 
results.  The  importance  of  saving  any  part  of  a  thumb  is  well 
recognised,  and  a  most  useful  digit  has  been  left  after  the 
removal  of  portions  of  the  metacarpal  bone  of  the  thumb. 
This  especiall}^  applies  to  cases  in  which  the  base  of  the  bone 
— which  represents  the  epiphysis — has  been  left. 

The  results  which  have  followed  the  resection  of  the  entire 
bone  have  not  been  very  satisfactory,  even  when  the  sub- 
periosteal method  has  been  carefully  carried  out.  This  method 
should  be  adopted  in  all  cases  of  excision  of  the  first  meta- 
carpal bone,  unless  distinctly  contra-indicated  or  impossible. 

Small  portions  of  the  shafts  of  the  metacarpal  bones  of  the 
fingers  have  been  removed  without  much  impairment  of  the 
hand ;  but  excision  of  the  entire  bone,  even  when  performed 
subperiosteally,  is  a  useless  operation.  The  finger  concerned 
is  deformed,  and  more  or  less  powerless  and  in  the  w^ay.  The 
same  may  be  said  of  such  excisions  as  involve  the  removal  of 
t;he  wliolo  of  the  epiphysis. 


614 


CHAPTER    X. 

Excision  of  the  Wrist. 

This  operation,  when  complete,  consists  in  the  removal  of 
the  whole  of  the  carpus,  the  lower  ends  of  the  radius  and  ulna, 
and  the  articular  extremities  of  the  metacarpus. 

It  has  been  performed  in  cases  of  chronic  bone  disease 
involving  the  carpus,  and  in  chronic  joint  disease  impUcating 
the  articulations  of  the  wrist  and  hand.  It  has  been  carried 
out  also  in  certain  cases  of  injury,  and  in  the  treatment  of 
gunshot  wounds,  unreduced  dislocations,  and  anchylosis. 

Excision  of  the  wrist  appears  to  have  been  first  performed 
by  Moreau  in  1794.  The  patient,  a  man  aged  71,  died.  The 
operation  was  not  favourably  regarded  by  surgeons,  and  for 
many  years  Moreau  had  few  imitators.  In  1865  Sir  Joseph 
Lister  pubHshed  an  account  of  an  operation  {Lancet,  voL  i., 
1865,  page  308)  in  which  he  for  the  first  time  insisted  upon 
the  importance  and  showed  the  possibility  of  removing  the 
whole  of  the  diseased  bones.  He  made  use  of  a  dorso-radial 
incision,  and  his  operation  was  no  doubt  the  forerunner  of  the 
methods  now  in  vogue. 

Boeckel  had  in  1862  employed  a  single  dorso-radial 
incision,  but  it  was  not  until  1867  {Gazette  med.  de  Stras- 
bourg, 1867,  page  184)  that  he  perfected  his  procedure  and 
appUed  the  subperiosteal  method  to  excision  of  the  wrist. 
Langenbeck  {Archiv.  filr  Idin.  Ghirurgie,  1874)  followed 
Boeckel  practically  without  modification.  Ollier's  operation — 
which  is  described  below  as  the  best  method — is  but  a  modi- 
fication f»f  the  original  procedure  of  Boe  kel. 

Anatomical  Points. — The  wrist-joint  is  separated  from 
the  lower  radio-ulnar  joint  by  the  triangular  cartilage  which 
is  attaclied  by  its  apex  to  the  styloid  process  of  the  ulna  and 
by  its  base  to  the  inner  margin  of  the  articular  surface  of  tlie 
raflins,  wliere  it  blends  with  the  articular  cartilage. 


EXCISIOX  OF    WRIST. 


615 


The  joint  is  protected  by  strong  tendons.  On  the  inner 
side  are  the  extensor  and  flexor  carpi  nlnaris;  on  the  outer 
side  the  extensor  ossis  metacarpi  pollicis,  the  extensores  primi 
and  secundi  internodii  poUicis,  and  the  two  radial  extensors  of 
the  carpus ;  hi  front  are  the  deep  and  superficial  flexors  of  the 
fingers,  the  flexor  lou- 
gus  pollicis,  palmaris 
longus,  and  flexor 
carpi  radiahs.  Pos- 
teriorly are  the  ten- 
dons of  the  extensor 
indicis,  extensor  com- 
munis, and  extensor 
minimi  digiti. 

These  tendons,  on 
passing  the  wrist,  are 
— with  the  exceptions 
of  the  palmaris  longus 
and  flexor  carpi  ul- 
naris  —  enveloped  by 
the  synovial  sheaths, 
the  positions  of  which 
are  shown  in  Fig.  174. 

The  bones  are 
united  by  means  of  a 

capsular  ligament  of  which  the  anterior  part  (the  so-called 
anterior  ligament)  is  the  strongest  portion.  The  posterior 
part  is  quite  thin.  More  substantial  fibres  exist  upon  the 
lateral  parts  of  the  capsule — the  so-called  external  and  mternal 
lateral  ligaments. 

A  more  or  less  complete  layer  of  ligamentous  tissue  covers 
the  anterior  and  posterior  surfaces  of  the  carpus,  and  to 
thickened  portions  of  it  various  names  are  given.  Olher 
would  have  the  carpus  regarded  surgically  as  one  short  wide 
bone,  capped  with  cartilage  at  either  end,  and  covered  with 
hgamentous  tissue  of  unequal  thickness. 

In  the  wrist  and  the  carpus  are  seven  separate  synovial 
sacs,  the  disposition  of  six  of  which  is  shown  in  Fig.  175.  The 
seventh  sac  is  a  minute  one  between  the  pisiform  and  cunei- 
form hemes. 


174. — SECTION     THEOUliH    THE    WEIBX 

Ileiilc.) 

Scaphoid  ;  B,  Os  magnum  ;  c,  Semilunar  ;  D,  Semi- 
lunar ;  E,  Unciform  ;  V,  Cuneiform  ;  G,  Pisiform  ; 
H,  Compartment  for  flexor  tendons ;  i,  Flexor 
carpi  radialis  ;  j,  Extensor  ossis,  metacarpi  pollicis, 
and  extensor  primi ;  K,  Extensores  carpi  radialis 
longior  and  brevior  ;  L,  Extensor  secundi  inter- 
nodii pollicis ;  M,  Extensores  communis  and 
indicis  ;  N,  Extensor  minimi  digiti ;  o,  Extensor 
carpi  ulnaris  ;  P,  Palmaris  longus  ;  a,  Ulnar 
vessels  ;  b,  Kadial  vessels  ;  1,  Ulnar  nerve. 


616 


OPERATIVE    SURGE  BY. 


It  will  be  observed  that  tbe  sac  between  the  trapezium  and 
the  first  metacarpal  bone  is  quite  distinct. 

Figs.  176  and  177  show  the  position  and  extent  of  the  lower 
epiphyses  of  the  radius  and  ulna.     They  join  Avith  the  shafts 

of  their  respective  bones 
about  the  twentieth  year. 
The  lower  extremity  of  the 
diaphysis  of  the  ulna  just 
reaches  to  the  radio-ulnar 
joint ;  the  lower  end  of  the 
diaphj^sis  of  the  radius  is 
intra-synovial. 

The  carpus  is  entirely 
cartilaginous  at  birth,  and 
the  bones  commence  to 
ossify  between  the  first 
year  (os  magnum)  and  the 
twelfth  year  (pisiform) 
after  birth.  The  tra- 
pezium is  an  important 
bone  from  an  operative 
point  of  view.  It  supports 
the  thumb,  is  in  very 
close  relation  with  the 
radial  artery,  forms  a 
groove  for  the  flexor  carpi  radialis,  and  gives  attachment  to 
the  opponens  poUicis,  the  abductor  poUicis,  and  the  flexor 
brevis  pollicis. 

The  tendons  at  the  back  of  the  wrist  can  be  well  made  out 
in  the  healthy  hand.  The  most  conspicuous  belongs  to  the 
extensor  secundi  internodii  pollicis.  It  is  rendered  distinct 
when  the  thumb  is  extended  and  abducted.  It  leads  up  to 
a  small  but  prominent  bony  elevation  on  the  back  of  the  radius, 
which  marks  the  outer  border  of  the  osseous  groove  for  its 
reception.  This  tendon,  when  it  reaches  the  radius,  points  to  the 
centre  of  the  posterior  surface  of  that  bone,  and  indicates  also 
roughly  the  position  of  the  interval  between  the  scaphoid  and 
semilunar  bones. 

The  lower  end  of  the  ulna  is  very  distinct.  When  the 
hand   is   supine,  its  styloid   process  is  exposed  at  the  inner 


CAVITIES    OF    THE 


EXCISION  OF  WRIST. 


ar, 


and  posterior  aspect  of  the  wrist  to  the  inner  side  of  the 
extensor  carpi  ulnaris.  In  pronation,  however,  the  process  is 
rendered  less  distinct,  while  the  head  projects  prominently  ou 
the  posterior  part  of  the  wrist,  and  is  found  to  lie  between  the 
tendons  of  the  extensor  carpi 
nlnaris  and  extensor  minimi 
ditj^iti. 

The  tip  of  the  styloid  pro- 
cess of  the  ulna  corresponds  to 
the  line  of  the  wrist-joint,  and 
a  knife  introduced  below  that 
joint  would  enter  the  articula- 
tion. 

A  knife  entered  horizon- 
tally just  below  the  tip  of  the 
styloid  process  of  the  radius 
would  hit  the  scaphoid  bone. 

A  line  drawn  between  the 
two  styloid  processes  slopes 
downwards  and  outwards ;  its 
two  extremities  represent  the 
extreme  inferior  limits  of  the 
radio-carpal  joint,  and  it  fairly 
corresponds  to  the  chord  of  the 
arc  formed  by  the  line  of  that 
joint.  The  line  between  the 
styloid  procesises  is  nearly  half  an  inch  below  the  summit  of 
the  arch  of  the  Avrist-joint. 

The  radial  artery  winds  round  to  the  back  of  the  -vvrist, 
just  below  the  styloid  process  of  the  radius,  lying  upon  the 
external  lateral  ligament  of  the  joint,  and  between  the 
extensors  of  the  metacarpal  bone  and  first  phalanx  of  the 
thumb.  It  then  runs  over  the  scaphoid  and  trapezium, 
and,  as  it  is  about  to  dip  between  the  two  heads  of  the 
abductor  indicis,  is  close  to  the  carpo-metacarpal  joint  of  the 
thumb. 

The  position  of  such  branches  of  the  radial  and  ulnar 
arteries  as  are  distributed  in  the  neighbourhood  of  the  wrist 
must  be  borne  in  mind.  The  vessels  most  apt  to  be  Avounded 
in  excision  of  the  wrist  are  the  radial,  the  deep  palmar  arch. 


fi 

Fig.  176.— LOWEE  END    OF   THE   EADITTS 

IN  A  SUBJECT  AGED  16.  [After  Oilier.) 

A,  Epiphysis  ;  B,  Lateral  ligament  ;  c, 
Synovial  membrane  of  radio-ulnar 
joint ;  D,  Triangular  ligament. 


618 


OPERATIVE    l^iUUGEEY. 


the   anterior  and    posterior   carpal    arches,   and   the    dorsal 
interosseous  branch  of  the  radial. 

1.  Ollier's  Operation  (by  two  Dorsal  Incisions). 
Those  surgeons  who  have  most  conspicuously  concerned 
themselves  with  excision  of  the  ^vrist  urge  that  the  opera- 
tion should,  whenever  possible,   be   performed  by  the   sub- 
periosteal    method,     and     that     that 
method   should  be   observed   even   in 
instances   when    it   must   on  account 
of  local  conditions  be  of  necessity  in- 
complete. 

Ollier's  operation  appears  to  me  to 
be  the  best  of  the  many  methods 
which  are  at  present  employed  for  ex- 
cising the  wrist.  The  procedure  is 
merely  a  modification  of  Boeckel's 
operation,  and,  so  far  as  the  external 
incisions  are  concerned,  does  not  differ 
ver}^  conspicuously  from  the  stiU.  older 
method  of  Lister. 

Operation. — The  patient  lies  upon 
the  back,  and  the  hand  is  placed  on  a 
small  table  by  the  side  of  the  opera- 
tion table,  and  is  allowed  to  rest  upon 
a  large  sand- bag  covered  with  mac- 
intosh. The  surgeon  sits  facing  the 
patient.  Such  adhesions  as  prevent  a 
moderate  degree  of  movement  should  be  broken  down.  It  is 
better  that  an  Esmarch's  tourniquet  should  not  be  used. 
The  operation  is  of  considerable  duration,  and  the  oozing 
which  follows  the  removal  of  the  elastic  band  is  usually  very 
considerable,  and  is  a  great  obstacle  to  healing. 

(a)  The  Incisions. — Two  landmarks  are  taken,  viz.,  the 
centre  of  a  line  uniting  the  two  styloid  processes  and  the 
tendon  of  the  extensor  indicis,  or,  in  default  of  it,  the  base  of 
the  second  metacarpal  bone.  The  radial  incision  commences 
opposite  to  the  centre  of  the  shaft  of  the  second  metacarpal 
bone,  and  is  continued  obliquely  upwards  along  the  outer  side 
of  the  extensor  indicis  tendon  to  a  point  cori'esponding  to  the 
centre  of  a  line  uniting  the  two  styloid  processes.     From  this 


Fig.  177. — LOWEE  END  OT 
THE    VJSSA.    IN    A    SUBJECT 

AGED  16.     [After  Oilier.) 

A,  Epiphysis ;  b,  Synovial 
membrane  ;  C,  Triangular 
ligament ;  D,  Lateral  liga- 
ment. 


EXCISION  OF   WRIST.  619 

point  the  incision  is  carried  vertically  upwards  in  the  line  of 
the  long  axis  of  the  limb  (Fig.  178,  a). 

In  a  large  hand  the  whole  incision  will  measure  about 
4i  mches — 3  inches  of  the  length  being  below  the  line  of  the 
articulation,  and  1^  inch  above  it. 

Having  divided  the  integuments,  the  surgeon  brings  the 
extensor  indicis  into  view,  but  without  opening  its  sheath. 

It  is  drawn  gently  outwards  by  means  of  a  hook,  and  the 
insertion  of  the  extensor  carpi  radialis  brevier  is  sought  for. 
The  knife  is  now  carried  well  down  to  the  bones  along  the 
whole  length  of  the  incision.  This  cut  will  commence  to  the 
inner  side  of  the  tendon  last  named,  and  will  fall  upon  the 
base  of  the  third  metacarpal. 

The  capsule  of  the  joint  is  opened,  the  posterior  annular 
ligament  is  divided,  and  the  upper  part  of  the  deep  incision 
falls  in  the  interval  between  the  extensor  indicis  and  the 
extensor  secundi  internodii  poUicis. 

The  former  tendon  is,  with  the  extensor  communis,  drawn 
inwards,  the  latter  outwards. 

The  ulnar  incision  is  now  made.  It  extends  fi-om  a  point 
one  inch  and  a  quarter  above  the  tip  of  the  uhaar  styloid 
process  to  a  point  one  inch  and  a  quarter  above  the  base  of 
the  fifth  metacarpal  bone.  It  is  placed  to  the  inner  side  of 
the  extensor  carpi  ulnaris. 

The  incision  is  carried  down  to  the  bones,  and  falls  upon 
the  ulna,  the  cuneiform,  and  the  unciform. 

In  making  these  incisions  care  should  be  taken  not  to  cut 
the  dorsal  branch  of  the  ulnar  nerve  to  the  little  finder,  or  the 
internal  division  of  the  dorsal  branch  of  the  radial  nerve. 

(h)  The  Removal  of  the  Carpus. — Starting  from  the  incisions 
already  made,  the  surgeon  proceeds  to  strip  the  carpal  bones  of 
their  ligamentous  and  periosteal  coverings.  Small  rugines  of 
various  shapes  are  used  for  this  purpose.  The  decortication 
may  be  m  )st  conveniently  commenced  on  the  radial  side,  and 
the  dorsal  aspect  of  the  bones  be  exposed  before  the  palmar. 
As  each  bone  is  freed,  it  should  be  seized  with  forceps  and 
removed.  Diseased  bone  is  removed  by  means  of  the  gouge. 
The  bones  of  the  ulnar  side  wiU  be  removed  through  the 
ulnar  incision. 

The  pisiform  bone  may  usually  be  left.      The  unciform 


620  OFERATIVE    SURGERY. 

process  may  be  cut  through  and  removed  subsequently  if 
found  diseased.  The  trapezium  should  be  saved  whenever 
possible. 

This  is  the  most  tedious  part  of  the  operation,  especially  if 
the  subperiosteal  method  be  strictly  adhered  to. 

(c)  The  Removal  of  the  Ends  of  the  Radius  and  Ulna. — 
The  hand  is  now  loose.  The  lower  ends  of  the  bones  of  the 
forearm  are  bared  of  periosteum  as  high  up  as  is  necessary. 
They  are  made  to  protrude  through  the  wound,  and  are  divided 
by  means  of  a  fine  saw.  If  very  little  disease  exists,  a  liberal 
gouging  of  the  parts  may  meet  the  needs  of  the  case. 

(d)  The  Removal  of  the  Ends  of  the  Metacarpal  Bones. — 
This  may  not  be  necessary.  As  little  of  these  bones  is 
removed  as  is  possible,  and  the  section  will  probably  extend 
no  further  than  the  limits  of  the  carpal  synovial  sacs. 

The  bones  are  made  to  project  through  the  wound,  and  are 
severed  as  required  by  means  of  a  fine  saw. 

(e)  The  wound  is  united,  a  drainage-tube  is  introduced,  and 
the  hand  is  adjusted  upon  a  special  splint. 

CoTtiment. — This  operation  must  be  subject  to  very  con- 
siderable modification.  It  is  tedious  and  difficult,  and  involves 
infinite  care.  It  may  be  impossible  to  carry  out  the  sub- 
periosteal method  completely.  Oilier  maintains  that  if  this 
method  be  completely  observed,  the  attachments  of  no  tendons 
are  lost. 

By  the  open  method  the  tendons  of  the  two  radial 
extensors  of  the  carpus,  the  tendons  of  both  the  extensor  and 
the  flexor  of  the  ulnar  side  of  the  carpus,  the  flexor  carpi 
radialis  tendon,  and  possibly  that  of  the  supinator  longus,  may 
be  sacrificed.  The  two  first-named  tendons  are,  indeed,  cut 
through. 

The  steps  of  the  operation  may  be  altered.  The  radius 
and  ulna  may  be  sawn  through  first,  and,  the  carpus  being 
exposed  in  the  wound,  the  bones  may  be  removed  one  by  one 
as  they  are  reached. 

By  this  means  the  palmar  surfaces  of  the  carpal  bones 
can  be  more  easily  fi-eed  of  their  periosteo-ligamentous 
covering. 

If  a  considerable  portion  of  both  radius  and  ulna  has  to  be 
removed,  each  bone  may,  when  freed  of  periosteum,  be  divided 


EXCISION  OF  WBIST. 


G21 


by  a  fine  chain  saw.     Throughout  the  operation  small  instru- 
ments and  ffood  retractors  must  be  used. 

The  decortication  of  the  bones  is  very  difficult  in  certain 
cases  and  in  other  than  young  subjects.  On  the  ordinary 
dissecting-room  subject  it 
is  often  almost  impossible. 
When  the  parts  have  long 
been  involved  in  chronic 
inflammation,  the  separa- 
tion of  the  periosteum  is 
easier. 

In  most  cases  the  hand 
is  already  distorted,  the 
joints  are  stiff,  the  soft  parts 
are  greatly  thickened,  the 
area  of  the  operation  is 
occupied  by  many  sinuses, 
and  the  synovial  sheaths 
of  the  tendons  have  been 
more  or  less  obliterated  by 
disease. 

2.  Other  Methods. 

It  is  needless  to  speak 
of  the  method  of  excising 
the  wrist  through  a  dorsal 
flap,  as  practised  by  Vel- 
peau,  nor  of  the  H -shaped 
incisions  once  in  vogue. 

Maisonneuve  in  1853 
(Gazette  des  Hopitaux, 
1853,  page  280)  made  use  of 

a  single  median  dorsal  incision,  and  of  late  jears  more  than 
one  surgeon  has  revived  this  procedure  in  a  modern  form. 

(a)  BoeckeVs  Operation. — This  is  sometimes  described  as 
Langenbeck's  operation,  the  two  procedures  being  practically 
identical.  A  single  dorsal  incision  is  made  upon  the  radial 
side.  This  incision  is  straight,  is  placed  in  the  interval  between 
the  extensor  indicis  and  the  extensor  secundi  internodii  pollicis, 
and  is  made  to  closely  follow  the  radial  border  of  the  first  of 
these  tendons  (Fig.  178,  b).   In  a  large  hand  the  incision  is  about 


178. — EXCISION   Of   THB   WlvisT. 


Ollier's  incision  for  I'adial  side 
Boeckel's  incision. 


622  OPERATIVE    8UEGEBY. 

four  and  three-quarter  inches  in  length,  extending  three  and 
a  quarter  inches  below  the  joint-line,  and  one  inch  and  a  half 
above  it.  In  a  small  hand  the  cut  would  be  about  three  and 
a  half  inches  in  length,  reaching  one  inch  and  a  quarter 
above  the  line  of  the  articulation,  and  two  and  a  quarter 
inches  below  it. 

The  tendons  of  the  extensors  of  the  radial  side  of  the 
carjjus  are  cut,  the  operation  is  carried  out  subperiosteally, 
and  in  the  manner  already  described. 

The  incision  is  not  quite  so  conveniently  placed  in  this 
operation  as  it  is  in  Ollier's,  and  the  latter  procedure  is 
rendered  simpler  by  the  introduction  of  a  small  ulnar  in- 
cision. 

Boeckel's  incision  renders  it  almost  impossible  to  avoid 
cutting  the  extensor  carpi  radialis  brevior  tendon. 

The  bend  in  the  wound-line  in  Olher's  operation  is  mainly 
for  the  purpose  of  avoiding  this  tendon. 

(6)  Sir  Joseph  Lister's  Operation. — This  may  be  taken  as 
a  good  example  of  the  open  method  of  excision,  as  distin- 
guished from  the  subperiosteal  plan. 

The  operation  is  thus  described  by  Mr.  Jacobson,  his 
account  being  a  little  fuUer  than  that  given  in  the  original 
text.  The  radial  incision  is  made  as  in  Fig.  179: — "This 
incision  is  planned  so  as  to  avoid  the  radial  artery,  and  also 
the  tendons  of  the  extensor  secundi  internodii  and  indicis. 
It  commences  above,  at  the  middle  of  the  dorsal  aspect  of  the 
radius,  on  a  level  with  the  styloid  process.  Thence  it  is  at 
first  directed  towards  the  inner  side  of  the  metacarpo- 
phalangeal joint  of  the  thumb,  running  parallel  in  this  course 
to  the  extensor  secundi  internodii ;  but  on  reaching  the  Hne  of 
the  radial  border  of  the  second  metacarpal  bone,  it  is  carried 
downwards  longitudinally  for  half  its  length,  the  radial  artery 
being  thus  avoided,  as  it  Ues  a  Uttle  farther  out.  These  direc- 
tions will  be  found  to  serve,  however  much  the  parts  may  be 
obscured  by  inflammatory  thickening.  The  tendon  of  the 
extensor  carpi  radialis  longior  is  next  detaclied  with  the  knife, 
guided  by  the  thumb-nail,  and  raised,  together  with  that  of 
the  extensor  brevior,  also  cut ;  Avhile  the  extensor  secundi 
internodii,  with  the  radial  artery,  is  thrust  someAvhat  outwards. 
The  next  step  is  the  separation  of  the  trapezium  from  the  rest 


EXCISION  OF   WRIST.  623 

of  the  carpus  by  cutting  forceps  applied  in  a  line  Avith  the 
longitudinal  part  of  the  incision,  great  care  being  taken  of  the 
radial  artery.  The  removal  of  the  trapezium  is  left  till  the 
rest  of  the  carpus  has  been  taken  away,  when  it  can  be  dis- 
sected out  without  much  difficulty,  whereas  its  intimate 
relations  with  the  artery  and  neighbouring  parts  would  cause 
much  trouble  at  an  earlier  stage.  The  soft  parts  on  the  ulnar 
side  are  next  dissected  up  as  far  as  possible,  the  hand  being 
bent  back  to  relax  the  extensors. 

"  The  ulnar  incision  should  be  made  very  free,  by  entering 
the  knife  at  least  two  inches  above  the  end  of  the  ulna 
immediately  anterior  to  the  bone,  and  carrying  it  down 
bctAveen  the  bone  and  flexor  carpi  ulnaris,  and  on  in  a  straight 
line  as  far  as  the  middle  of  the  fifth  metacarpal  bone  at  its 
palmar  aspect.  The  dorsal  lip  of  the  incision  is  then  raised, 
and  the  tendon  of  the  extensor  carpi  ulnaris  cut  at  its 
insertion,  and  its  tendon  dissected  up  from  its  groove  in  the 
ulna,  care  being  taken  not  to  isolate  it  from  the  integuments, 
which  would  endanger  its  vitality.  The  finger  extensors  are 
then  separated  from  the  carpus,  and  the  dorsal  and  internal 
lateral  ligaments  of  the  wrist-joint  divided ;  but  the  connec- 
tions of  the  tendons  with  the  radius  are  purposely  left  undis- 
turbed. 

"  xVttention  is  now  directed  to  the  palmar  side  of  the  incision. 
The  anterior  surface  of  the  ulna  is  cleared  by  cutting  towards 
the  bone  so  as  to  avoid  the  artery  and  nerve,  the  articulation 
of  the  pisiform  bone  opened,  if  that  has  not  been  already  dona 
in  making  the  incision,  and  the  flexor  tendons  separated  from 
the  carpus,  the  hand  being  depressed  to  relax  them.  While 
this  is  being  done,  the  knife  is  arrested  by  the  unciform 
process,  which  is  clipped  through  at  its  base  with  pliers. 

"  Care  is  taken  to  avoid  carrying  the  knife  farther  down  the 
hand  than  the  bases  of  the  metacarpal  bones  ;  for  this,  besides 
inflicting  unnecessary  injury,  would  involve  risk  of  cutting  the 
deep  palmar  arch.  The  anterior  ligament  of  the  wrist-joint  is 
also  divided,  after  which  the  junction  between  the  carpus  and 
metacarpus  is  severed  with  cutting  pliers,  and  the  carpus  is 
extracted  from  the  ulnar  incision  with  sequestrum  forceps,  and 
by  touching  with  the  knife  any  ligamentous  connections. 

"  The  hand  being  now  forcibly  everted,  the  articular  ends  of 


624 


OPERATIVE    SURGERY. 


the  radius  and  iiliia  will  protrude  at  tlie  ulnar  incision.  If 
they  appear  sound,  or  very  superficially  affected,  the  articular 
surfaces  only  are  removed.  The  ulna  is  divided  obliquely 
with  a  small  saw,  so  as  to  take  away  the  cartilage-covered 
rounded  part  over  which  the  radius  sweeps,  while  the  base  of 
the  styloid  process  is  retained.  The  ulna  and  radius  are  thus 
left  of  the  same  length,  which  greatly  promotes  the  symmetry 

and  steadiness  of  the  hand,  the 
angular  interval  between  the 
bones  being  soon  filled  up  with 
fresh  ossific  deposit.  A  thin 
slice  is  then  sawn  off  the  radius 
parallel  with  the  articular 
surface.  For  this  it  is  scarcely 
necessary  to  disturb  the  ten- 
dons in  their  grooves  on  the 
back,  and  thus  the  extensor 
secundi  internodii  may  never 
appear  at  all. 

"  This  may  seem  a  refine- 
ment,  but    the    freedom   with 
which  the  thumb  and  fingers 
can  be  extended,  even  within  a 
day  or  two   of  the   operation, 
when  this  point  is  attended  to,  shows  that  it  is  important. 
The  articular  facet   on   the   ulnar   side  of  the  bone  is  then 
clipped  away  with  forceps  applied  longitudinally. 

"  If  the  bones  prove  to  be  deeply  carious,  the  pliers  or  gouge 
must  be  used  with  the  greatest  freedom.  The  metacarpal 
bones  are  next  dealt  with  on  the  same  jDrinciple,  each  being 
closely  investigated — the  second  and  third  being  most  readily 
reached  from  the  radial,  the  fourth  and  fifth  from  the  ulnar 
side.  If  they  seem  sound,  the  articular  surfaces  only  are 
chpped  oft",  the  lateral  facets  being  removed  by  longitudinal 
application  of  the  pliers. 

"  The  trapezium  is  next  seized  with  forceps  and  dissected 
out,  without  cutting  the  tendon  of  the  flexor  carpi  radialis, 
which  is  firmly  bound  down  in  the  groove  on  the  palmar 
aspect,  the  knife  being  also  kept  close  to  the  bone  to  avoid 
the  radial.    The  thumb  being  then  pushed  up  by  an  assistant, 


Fi". 


79. — excision   of  the 

(lister's  incision.) 


EXCISION  OF   WRIST. 


625 


the  articular  end  of  the  metacarpal  bone  is  removed.  Though 
this  articulates  by  a  separate  joint,  it  may  be  affected,  and 
the  symmetry  of  the  hand  is  promoted  by  reducing  it  to  the 
same  level  as  the  other  metacarpals. 

"  Lastly,  the  articular  surface  of  the  pisiform  is  clipped  off, 
the  rest  being  left,  if  sound,  as  it  gives  insertion  to  the  flexor 
carpi  ulnaris,  and  attachment  to  the  anterior  annular  ligament." 

After-treatment. — The  wound  must  be  Avell  drained,  be 
dressed  with  the  most  careful  antiseptic  precautions,  and  the 
cavity  of  the  wound  be  fi-equently  washed  out. 

The  limb  must  be  maintained  upon  a  splint  which  will 
support  the  palm  of  the  hand,  will  keep  the  wrist  a  Uttle  ex- 
tended, and  the  fin- 
gers a  little  flexed, 
while  at  the  same 
time  it  will  not  pre- 
vent movements  of 
the  fingers  from 
being  carried  out. 
Lister's  wooden  splint 
with  a  cork  pad  is 
simple,  and  answers 
well  (Fig.  180). 

The  splint  used 
by  OUier  is  shown 
in   Fig.  181.      It   is 

made  of  wire,  and  when  in  actual  use  is  lined  with  lint  or 
cotton- wooL  It  has  this  advantage— that  the  supporting  iron 
can  be  bent,  and  the  position  of  the  part  therefore  changed 
from  time  to  time  as  the  patient  progresses.  The  wound, 
moreover,  is  more  accessible. 

The  thumb  is  apt  to  be  drawn  inwards  to  the  index  finger. 
This  is  prevented  in  Lister's  splint  by  the  use  of  a  suitable 
pad.  In  OUier  s  splint  a  wire  loop  (a)  enables  the  thumb  to  be 
maintained  in  any  position  wished. 

There  is  a  constant  tendency  for  the  hand  to  assume  the 
position  of  adduction,  and  this  is  apt  to  become  more  marked 
some  time  after  the  splint  has  been  removed. 

The  limb  will  need  to  be  maintained  upon  a  splint  for  a 
considerable  period,  varying  fi'om  two  to  six  months. 


SPLINT     FOE    EXCISION    OF     THE 


626  OPERATIVE    SUEGEBY. 

It  is  essential  during  the  whole  of  this  time  that  passive 
movements  of  the  fingers  be  kept  up.  The  fingers  should  be 
moved  as  earl}^  as  the  third  day.  The  wrist  should  be  kept 
at  rest  until  the  parts  have  become  consolidated,  when  passive 
movements  may  be  commenced.  Active  movements  of  the 
fingers  should  be  undertaken  as  soon  as  the  patient  can  move 
without  pain. 

For  some  time  after  the  splint  is  left  off,  the  patient  should 
wear  a  leather  support,  and  should  be  persistent  in  his  attempts 


Fig.  181.— olliee's  wire  splint  foe  excision  of  the  weist. 
a,  Support  for  the  thumb,  if  required. 

to  exercise  the  wrist  and  fingers,  and  to  increase  the  range  of 
their  movements. 

Results. — The  results  of  this  operation  are,  on  the  whole, 
not  very  satisfactory.  Since  the  introduction  of  antiseptic 
measures  the  mortality  is  low,  but  is  nevertheless  higher 
than  that  which  attends  amputation  of  the  forearm.  In  very 
carefully  selected  and  very  favourable  cases  some  results 
have  certainly  been  excellent.  Oilier  records  several  instances 
in  which  the  patient  recovered  with  a  very  useful  hand, 
capable  of  performing  a  large  series  of  movements,  to  support 
weights,  and  to  bear  pressure.  In  such  cases  fibrous  anchy- 
losis has  taken  place,  leaving  a  moderate  degree  of  movement 
at  the  wrist,  and  a  free  action  of  the  tendons  of  the  fingers. 

In  contrast  to  one  such  conspicuous  result  must  be  placed 
a  large  number  of  reported,  and  possibly  a  still  larger  number 


EXCISION  OF   WBIST.  627 

of  unreported,  cases  in  which  a  malformed  and  useless  hand 
has  resulted — a  hand  thickened,  rigid,  and  uncouth,  with 
stiffened  fingers,  fixed  tendons,  and  open  sinuses^ — a  limb  the 
seat  of  continued  pain,  and  more  or  less  completely  useless. 

In  the  most  common  form  of  trouble  involving  the  carpus 
and  Avrist-joint — viz.,  strumous  disease  of  bone  and  synovial 
membrane — excision  of  the  wrist  can  only  in  quite  exceptional 
cases  be  justifiable.  Under  long-continued  and  careful  treat- 
ment, which  will  involve  the  removal  of  diseased  tissue  from 
time  to  time,  the  majority  of  these  cases  do  very  fairly  well ; 
and  if  the  disease  will  not  yield  to  such  measures,  it  may  be 
doubted  whether  either  the  patient  or  the  limb  is  in  a  favour- 
able condition  for  so  extensive  an  operation  as  the  present 
procedure  involves. 


o  o2 


628 


CHAPTER    XL 

Excision  of  the  Radius  and  Ulna. 

Portions  of  the  bones  of  the  forearm,  and  indeed  the 
whole  of  the  diaphysis  of  one  or  both  of  these  bones,  have 
been  removed  by  operation  for  the  rehef  of  various  con- 
ditions. 

These  operations  have  been  carried  out  in  cases  of  exten- 
sive bone  disease,  in  certain  instances  of  gunshot  injury,  in 
cases  of  new  growth  (myeloid  sarcoma)  attacking  the  bones, 
and  in  some  examples  of  deformity  following  injury. 

The  whole  subject  is  very  fully  dealt  with  by  Oilier  in  his 
Traite  des  Resections  (vol.  ii.,  1889). 

The  Ulna. — The  ulna,  being  a  comparatively  superficial 
bone,  is  easily  reached.  Its  posterior  border  is  subcutaneous 
from  the  olecranon  to  the  styloid  process. 

The  incision  is  made  along  this  posterior  border,  and  the 
bone  is  reached  between  the  anconeus  and  the  flexor  carpi 
ulnaris  in  the  highest  part  of  the  diaphysis  and  between  the 
latter  muscle  and  the  extensor  carpi  ulnaris  in  the  lower  two- 
thirds  or  three-fourths  of  the  bone.  The  chief  mass  of  mus- 
cular tissue  from  which  the  bone  must  be  freed,  belongs  in 
the  flexor  profimdus  digitorum,  which  is  extensively  attached 
to  both  the  anterior  and  the  internal  surfaces. 

It  must  be  remembered  that  the  dorsal  branch  of  the  ulnar 
nerve  winds  backwards  beneath  the  flexor  carpi  ulnaris  at 
about  some  two  to  three  inches  above  the  wrist. 

Whenever  possible,  the  resection  of  the  bone  should  be 
carried  out  by  means  of  the  subperiosteal  method. 

The  Radius. — The  bone  is  approached  from  the  external 
surface  by  an  incision  parallel  to  the  long  axis  of  the  bone, 
and  so  placed  as  to  open  the  interstice  between  the  supinator 
longus  and  extensor  carpi  radialis  longior  muscles. 

Tn  this  inter-muscular  space  the  radial  nerve  is  sought  for. 


EXCISION  OF  RADIUS   AND    ULNA.  629 

This  nerve  lies  throughout  beneath  the  supinator  longus,  but 
about  three  inches  above  the  wrist  it  turns  backwards  beneath 
the  tendon  of  the  muscle  to  become  subcutaneous.  The 
nerve  may  be  followed  up  until  the  point  is  reached  at  which 
the  musculo-spiral  bifurcates  into  the  radial  and  posterior  inter- 
osseous nerves. 

The  periosteum  is  divided  over  the  outer  border  of  the 
bone,  and  the  insertion  of  the  pronator  teres  separated  and 
turned  forwards.  The  supinator  brevis  muscle  is  divided 
vertically ;  one  part  is  turned  forwards  with  the  radial  nerve, 
the  other  is  turned  backwards  with  the  posterior  interosseous 
nerve. 

This  method  of  exposing  the  radius  originated  with  Mr. 
Henry  Morris,  whose  very  successful  case  of  removal  of  a 
considerable  part  of  both  the  radius  and  the  uhia  was 
published  in  the  tenth  volume  of  the  Clinical  Society's 
Transactions. 

The  excision  should  be  subperiosteal  whenever  possible. 
In  the  case  of  operation  for  sarcoma,  this  method  would, 
however,  not  be  admissible. 

In  young  subjects  the  restoration  of  parts  after  subperi- 
osteal resection  of  the  diaphysis  of  these  bones— and  notably 
of  the  radius — has  been  very  complete  and  remarkable.  On 
the  other  hand,  very  lamentable  deformity  has  attended 
extensive  resections  of  the  radius  in  which  the  periosteum 
was  not  preserved,  or  in  which  the  epiphyses  were  encroached 
upon. 


630 


CHAPTER    XII. 

Excision  of  the  Elbow. 

This  operation  consists  in  the  removal  of  the  lower  end  ot 
the  humerus  and  the  upper  extremities  of  the  radius  and  ulna. 

It  is  performed  for  advanced  cases  of  bone  and  joint 
disease  which  have  resisted  milder  treatment ;  for  certain  cases 
of  injury,  notably  gunshot  wounds ;  for  the  relief  of  anchylosis 
when  in  a  faulty  position ;  and  for  some  examples  of  un- 
reduced dislocation.  The  object  aimed  at  is  the  production  of 
a  movable  joint.  A  description  of  the  operation  upon  the 
dead  body  was  given  in  1782  by  Park  ("  On  a  New  Method 
of  treating  Diseases  of  the  Knee  and  Elbow,"  1783),  and  in 
the  same  year  excision  of  the  elbow  was  proposed  by  Moreau 
{Memoire  a  VAcademie  de  Ghirurgie,  1782). 

The  first  actual  operation  appears  to  have  been  performed 
by  Moreau  in  1794.  Previous  to  1782  large  fragments  of  dead 
bone  had  been  removed  from  the  elbow  by  operation,  and  the 
lower  end  of  the  humerus  had  been  excised  in  at  least  one 
case  of  compound  dislocation  (Wainman,  1759), 

In  England  the  ojjeration  was  popularised  by  Syme,  and 
was  enthusiastically  adopted  by  British  surgeons. 

Anatomical  Points.— The  elbow  is  a  pure  hinge-joint, 
permitting  normally  of  no  lateral  movement.  The  synovial 
membrane  of  the  superior  radio-ulnar  joint  joins  that  of  the 
major  articulation. 

The  crease  in  the  skin  called  the  "  fold  of  the  elbow  "  is 
placed  some  little  way  above  the  line  of  the  joint. 

The  bony  points  about  the  elbow  can  be  well  made  out  in 
a  healthy  subject. 

The  internal  condyle  is  the  more  prominent  and  the  less 
rounded  of  the  two.  The  humcro-radial  articulation  forms 
a  horizontal  line,  but  the  humero-ulnar  joint  is  oblique,  the 
joint  surfaces  sloping  downwards  and  inwards.  Thus  it 
happens  that  while  the  outer  condyle  is  only  three-quarters 


EXCISION  OF  ELBOW. 


631 


of  an  inch  above  the  articular  hne,  the  tip  of  the  internal 
condyle  is  more  than  one  inch  above  that  part. 

A  line  drawn  through  the  two  condyles  will  be  at  right 
angles  with  the  axis  of  the  upper  arm,  while  it  will  form  an 
angle  with  the  axis  of  the  forearm. 

The  joint-line  is  equivalent  to 
only  about  two-thirds  of  the  width 
of  the  entire  line  between  the 
points  of  the  two  condyles. 

In  extreme  extension  the  tip  of 
the  olecranon  is  a  httle  above  the 
Hne  joining  the  two  condyles. 

Of  the  ligaments  of  the  elbow- 
joint  the  anterior  and  posterior  are 
comparative!}'  thin.  The  internal 
lateral  is  the  strongest  and  most 
extensive  of  the  ligaments.  In  ex- 
cision it  is  very  important  that  the 
external  lateral  ligament  should  be, 
whenever  possible,  preserved,  since 
it  joins  below  with  the  articular 
ligament. 

The  three  most  important  muscles  in  relation  to  this 
operation  are  the  biceps,  the  brachialis  anticus,  and  the  triceps. 
The  insertion  of  the  two  tirst-named  muscles  should  never 
be  divided.  The  biceps  is  inserted  into  the  tubercle  of  the 
radius,  the  brachialis  anticus  into  the  anterior  surface  of  the 
ulna  at  the  root  of  the  coronoid  process.  A  section  of  the 
ulna  sufficiently  low  to  include  the  whole  of  the  coronoid 
process  will  not  involve  a  sacrifice  of  the  insertion  of  the 
brachialis  anticus.  The  triceps  insertion  occupies  not  only 
the  upper  flat  surface  of  the  olecranon,  but  also  a  considerable 
portion  of  each  of  the  sides  of  that  process. 

From  the  triceps  tendon  come  of!"  two  considerable  lateral 
expansions,  which  descend  obliquely  to  join  the  deep  fascia  of 
the  forearm  (Fig.  188).  Of  these  the  internal  is  insignifi- 
cant. The  external  expansion  is,  however,  considerable, 
and  should  always  be  saved,  as  it  enables  the  triceps  to 
retain  a  hold  of  the  f  irearm,  even  after  the  olecranon  has  been 
removed. 


Fig.  182. — DIAGEAM  OF    HUMERUS 
AT   AGE    OF    15. 

A,  Internal  condyle  ;  B,  Line  of 
attachment  of  anterior  part  of 
capsule. 


632 


OPERATIVE    SURGERY. 


The  anconeus  and  supinator  brevis  muscles  must  be 
seriously  disturbed  in  any  excision  of  the  elbo^v.  The  other 
muscles  in  ver}'-  immediate  relation  with  the  joint  are  the 
extensor  carpi  radiahs  brevior  and  the  extensor  carpi  ulnaris. 


One 
damasre  to,  the 


great 


danger 


Fig.      183.— XTPPEE      iND      OF 
THE   EABIUS  IN  A    SUBJECT 

AGED  15.      {.After  Oilier.) 

A.  Epiphysis  ;  B  B',  Sjmovial 
membrane. 


m   this    operation   is   division   of,   or 
ulnar  nerve  as  it  lies  in  the  groove  bet'ween 
the  olecranon  and  the  internal  con- 
dyle. 

Another  nerve  which  is  very 
readily  injured  in  this  operation  is  the 
posterior  interosseous,  which  is  placed 
in  jeopardy  when  the  upper  end  of  the 
radius  is  being  bared. 

The  composition  of  the  arterial 
plexus  which  surrounds  the  elbow- 
joint  on  all  sides,  and  supphes  it, 
must  be  held  in  mind. 

The  lower  epiphysis  of  the  hu- 
merus is  of  large  size,  and  contains 
four  separate  osseous  nuclei.  The  main 
mass  of  the  epiphysis  joins  the  shaft 
about  the  sixteenth  or  seventeenth 
year,  the  nucleus  forming  the  internal  condyle  joins  at  the 
eighteenth  year.  That  part  of  the  epiphysis  which  forms  the 
radial  condyle  and  the  trochlea  is  within  the  capsule  of  the 
joint.  That  part  which  forms  the  two  condyles  is  without  the 
s}Tiovial  cavity  (Fig.  182). 

The  upper  epiphysis  of  the  radius  forms  the  head  of 
the  bone,  is  "wnthin  the  s}Tiovial  cavity  of  the  joint,  and 
joins  the  shaft  between  the  sixteenth  and  seventeenth  years 
(Fig.  183). 

The  olecranon  process  is  mainly  formed  from  the  diaphysis ; 
indeed,  more  than  three-fourths  of  its  gi-eater  sigmoid  cavity 
belongs  to  that  segment  of  the  bone. 

The  upper  part  of  the  olecranon  is  at  birth  cartilaginous. 
At  the  tenth  or  eleventh  year  a  small  nucleus  of  bone 
appears  on  the  highest  part  of  the  process,  and  forais  a  very 
slight  epiphysis,  which  represents  only  the  highest  or  flat  sur- 
face of  the  olecranon,  and  is  little  more  than  a  mere  shell  of 
bone.    This  little  epiphysis  joins  the  shaft  about  the  seven- 


EXCISION  OF  ELBOW. 


633 


IS 


placed 


on 


the 


teenth  year.  The  anterior  part  of  this  epiphysis  is  intra- 
synovial,  the  posterior  and  larger  part  is  subperiosteal 
(Fig.  184). 

1.  Excision  through  a  Posterior  Median  Incision. 

Operation. — The  patient  lies  upon  the  back,  with  the  body 
close  to  the  edge  of  the  table.  The  surgeon  stands  on  the 
side  to  be  operated  upon.  An  assistant 
opposite  side  of  the  table — i.e., 
upon  the  patient's  sound  side — 
and  holds  the  limb.  The  upper 
arm  should  be  vertical,  or  at 
right  angles  to  the  surface  of 
the  couch,  the  elbow  should  be 
a  little  flexed,  and  the  forearm 
be  carried  across  the  patient's 
chest,  so  that  the  elbow  pro- 
jects prominently  outwards  (Fig. 
186).  In  dealing  "svith  the  right 
joint  the  operator  should  stand 
by  the  patient's  loins ;  and  in 
dealing  with  the  left,  well  to 
the  outer  side  of  the  trunk.  A 
second  assistant,  standing  on  the 
opposite  side,  can  help  to  steady 
the  limb  by  grasping  the  arm 
and  forearm  as  he  leans  over 
the  body ;  and  a  third  helper, 
placed  to  the  surgeon's  left,  should  be  prepared  to  assist  in 
retracting  the  divided  parts. 

In  this  attitude  it  vnll  be  understood  that  the  ulna  and 
olecranon  will  be  uppermost. 

The  use  of  the  elastic  tourniquet  should  be  avoided  when 
possible. 

Narrow-bladed  rectangular  retractors  made  of  the  stoutest 
steel  are  requisite. 

(a)  The  Incision. — The  skin  incision  is  about  four  inches 
in  length,  is  in  the  long  axis  of  the  forearm,  and  is  so  placed 
as  to  cross  the  centre  of  the  olecranon  fossa  of  the  humerus, 
and  to  run  along  the  middle  of  the  olecranon  process,  and 
then  follow  the  crest  or  posterior  border  of  the  ulna  (Fig.  185). 


Fig.  184. — UPPER  EXD    OF  THE   TONA 
IN    A    SUBJECT     AGED     1.5.        {After 

Oilier.) 

A,  Epiphysis ;  B,  Posterior  ligament ; 
C,  Anterior  ligament. 


634 


OPEEATIVE    SURGERY. 


The  centre  of  the  incision  should  correspond  to  the  tip  or 
summit  of  the  olecranon,  so  that  two  inches  of  the  cut  Avill  be 
over  the  humerus,  and  two  inches  over  the  olecranon  and 
ulna. 

The  stout  short-bladed  excision  knife  may  be  carried 
at  once  down  to  the  bones,  cutting  on  to  the  olecranon, 
bisecting  the  triceps  tendon,  opening 
the  articulation  through  the  posterior 
ligament  and  reaching  the  back  of  the 
humerus. 

As  the  cut  will  be  made  from 
"  above  downwards,"  it  will  be  seen 
that  in  the  position  occupied  by  the 
limb  the  knife  will  cut  first  upon  the 
ulna,  which  is  uppermost,  and  then 
upon  the  humerus  (Fig.  186). 

(6)  The  Clearing  of  the  Olecranon 
and  the  Condyles  of  the  Humerus. — In 
clearing  the  bones  for  excision,  the  fol- 
lowing rules  should  be  observed : — (1) 
The  surgeon  should  keep  the  knife 
well  down  upon  the  bone,  and  his  inci- 
sions should  be  short  and  made  with 
force,  and  the  edge  of  the  blade  be  kept 
turned  towards  the  bones.  (2)  The 
periosteum  should  be  separated  to  as 
great  an  extent  as  is  possible,  and  all  ligamentous  connections 
should  be  spared.  The  operator  should  aim  at  leaving  the 
bones  absolutely  bare.  (3)  The  rugine  and  the  elevator  should 
be  freely  used,  while  the  knife  is  employed  sparingly.  The  left 
thumb-nail  must  be  used  with  vigour  to  retract  the  tissues  as 
soon  as  they  are  separated,  and  the  surgeon  may  expect  that 
the  thumb  of  his  left  hand  will  remind  him  of  the  operation 
for  many  days  after.  Good  retractors  must  also  be  employed 
at  every  step.  The  main  feature  of  the  operation  is  the 
efficient  peeling  of  the  olecranon  and  the  irregularly-shaped 
humerus. 

The  inner  part  of  the  wound  is  first  dealt  with. 
The  inner  half  of  the  triceps  tendon  is  peeled  from  the 
olecranon  with  as  much  periosteum  as  possible.     The  hollow 


iTig.    185. — EXCISION  OF  THE 
ELBOW. 

A,  Roux's  incision  ;  b,  Me- 
dian vertical  incision. 


EXCISION  OF  ELBOW. 


tjcir) 


between  the  olecranon  and  the  internal  condyle  is  now  cleared 
until  that  process  of"  bone  is  reached,  and  is  left  bare  and 
projecting. 

If  the  operator  keep  close  to  the  bones,  and  observe  the 
three  rules  just  laid  down,  there  is  no  reasonable  danger  of 


Fig.    186. — EXCISION   OF  THE    ELBOW  :     THE   CLEARING   OF   THE   HUMERUS. 


wounding  the  ulnar  nerve.  The  internal  lateral  hgament  is 
stripped  off  from  both  humerus  and  ulna,  and  the  periosteum 
is  so  separated  as  to  carry  with  it  the  origin  of  the  flexor 
muscles. 

The  surgeon  now  turns  to  the  outer  part  of  the  incision, 
separating  the  tissues  on  that  side  until  the  outer  condyle  is 
reached  and  laid  bare.  In  this  stage  of  the  operation  the 
outer  half  of  the  triceps  tendon  will  be  separated  and  drawn 
aside  without  severing  its  connection  with  the  deep  fascia  of 
the  forearm,  the  anconeus  will  be  raised  from  the  ulna,  the 
external  lateral  ligament  and  the  origin  of  the  mass  of 
extensor  muscles  will  be  separated  fi'om  the  humerus,  and 
the  supinator  brevis  will  be  turned  well  aside.  Here,  again, 
strong  retractors  are  of  great  service  (Fig.  186).  It  is  during 
this  part  of  the  procedure  that  damage  may  be  done  to  the 
posterior  interosseous  nerve. 


636 


OPEBATIVE    SURGERY. 


The  bones  of  tlie  joint  are  now  free  of  one  another  except 
upon  then*  anterior  aspect. 

(c)  The  Sawmg-off  of  the  End  of  the  Humerus. — The 
elbow  should  now  be  fully  flexed,  and  without  much  diffi- 
culty the  lower  end  of  the  humerus  can  be  made  to  project 


187. — EXCISION  OF  THE   ELBOW  :    SAWINd  OF  THE    HUMKUi:.: 

{Modified  from  Faraheuf.) 


into  the  wound.  The  patient's  hand  should  then  be  placed 
in  the  prone  position  upon  the  operating-table,  close  to  the 
patient's  head  upon  the  affected  side.  In  this  attitude  it  can 
be  firmly  held,  the  lower  ends  of  the  radius  and  ulna  being 
fixed  rigidly  upon  the  table.  The  assistant  who  grasps  the 
upper   arm   should   project   tlie   lower   end  of  the  humerus 


EXCISION  OF  ELBOW.  637 

upwards.  This  portion  of  bone  is  now  cleared  of  its 
few  attachments  in  front,  and  is  bared  as  high  up  as  is 
necessary. 

The  surgeon  then  grasps  the  bone  with  Hon  forceps  held  in 
the  left  hand,  and  maintained  vertically,  as  if  he  would  draw 
the  bone  directly  upwards  (Fig.  187). 

A  narrow  saw  with  a  movable  back  is  applied  horizontally 
to  the  lower  extremity  of  the  bone  so  fixed,  and  the  excision 
of  the  humerus  is  completed. 

The  saw-line  generally  crosses  the  bone  at  right  angles 
to  its  long  axis,  and  just  below  the  tips  of  the  condyles. 

In  using  the  saw  a  metal  retractor  or  spatula  should  be 
emplo3^ed  to  hold  back  and  retract  the  soft  parts. 

A  strip  of  bent  metal  of  the  form  shown  in  Fig.  187  answers 
admirably  for  this  purpose. 

{d)  The  Sawing-off  of  the  Ends  of  the  Radius  and  Ulna. — 
While  the  hmb  is  in  the  same  position  the  assistant  who 
is  fixing  the  forearm  relaxes  his  hold,  and  forcing  the  bones  of 
that  part  of  the  limb  upwards,  makes  them  in  turn  protrude 
prominently  in  the  wound.  The  ulna  is  grasped  with  the 
Uon  forceps,  which  are  again  held  vertically,  as  if  to  draw  the 
bone  directly  upwards  ;  and  the  metal  spatula  having  been 
appHed,  the  saw  is  applied  horizontally  to  the  base  of  the 
process,  a  shce  of  the  upper  end  of  the  radius  being  removed 
at  the  same  time  (Fig.  188). 

The  wound  is  washed  out,  is  adjusted  with  sutures,  and  a 
drainage-tube  is  inserted. 

Comment. — The  incision  here  described  is  that  of  Park 
and  Maisonneuve,  and  the  operation  represents  the  best 
method  now  in  vogue  for  excising  the  elbow,  and  the  method 
which — if  the  selection  made  by  text-books  be  a  criterion — is 
the  most  universally  adopted. 

The  operation  is  simple,  the  bones  are  easily  exposed  on 
each  side,  the  ulnar  nerve  is  well  guarded,  the  triceps  tendon 
is  subjected  to  the  least  amount  of  injury,  and  efficient 
drainage  is  provided  for. 

The  method  above  described  may  be  considered  to  follow 
the  open  method,  although  as  much  periosteum  and  ligamen- 
tous tissue  is  preserved  as  is  possible,  and  the  operation  is  of 
wide  application. 


638 


,    OPERATIVE    SURGE BT. 


The  complete  subperiosteal  excision  is  described  in  a 
chapter  which  follows. 

To  preserve  the  whole  of  the  periosteum  is  extremely 
difficult,  and  often  impossible  or  inadvisable.     In  the  above 

operation  the  bone  is  bared 
subperiosteally  as  far  as  is 
practical  in  the  great  ma- 
jority of  cases. 

The  projecting  end  of 
the  ulna  may  be  cut  off 
early  in  the  operation  in 
order  that  the  lower  ex- 
tremity of  the  humerus 
might  be  more  easily  ex- 
posed and  dealt  with. 

2.  The  Subperiosteal 
Method. 

The  operation  just  de- 
scribed is — if  it  be  carried 
out  as  detailed — as  nearly 
an  example  of  the  sub- 
periosteal method  as  is  in 
the  majority  of  instances, 
practicable. 

The   following    descrip- 
tion is  derived  from  Fara- 
beufs      account       of      the 
"  Methode  de  la  Rugine,"  as  distinguished  from  the  "  Methode 
du  Bistouri."     (See  page  603,  and  Fig.  170.) 

Operation. — (a)  The  Incision. — Precisely  the  same  incision 
is  employed  as  in  the  last  operation.  The  arm  is  placed  by 
the  patient's  side,  the  elbow  is  extended,  and  the  hand  prone. 
The  elbow  rests  upon  a  small,  hard,  round  cushion,  which  is 
placed  upon  the  table  by  the  side  of  the  patient's  body. 

The  incision  is  carried  well  down  to  the  bones,  so  as  to 
divide  the  periosteum  both  of  the  humerus  and  olecranon,  to 
open  the  joint  capsule,  and  bisect  the  triceps  tendon. 

In  the  position  the  limb  now  occupies,  the  external  or 
radial  lip  of  the  wound  will  be  superior,  and  the  internal  lip 
inferior  or  the  nearer  to  the  cushion. 


-.-2 
Fig.  188. — A,  EIGHT  ELBOW  AFTEB  EXCI- 
SION BT  DOESAii  INCISION.  {After  Farci- 
heuf.) 
A,  Humerus  ;  B,  Ulna ;  C,  Supinator  longus 
and  radi.al  extensor  of  the  carpus  ;  D, 
Outer  expansion  from  triceps  tendon  ;  d', 
Inner  expansion  from  the  same. 

B,    PARTS   EEMOVED   IN   THE   EXCISION. 

A,  Humerus  ;  B,  Ulna  ;  C,  Kadius. 


EXCISION  OF  ELBOW.  639 

(h)  Decortication  of  the  Postero-external  Parts. — Com- 
mencing with  the  superior  or  external  part  of  the  wound,  the 
surgeon  exposes  the  depths  of  the  original  cut,  and  draws  the 
soft  parts  well  aside  by  means  of  proper  retractors. 

With  a  rugine  and  elevator  he  then  proceeds  to  lay  bare 
the  outer  part  of  the  olecranon,  pressing  forwards  with  the 
rugine  until  he  has  reached  the  articular  surface  of  the 
olecranon,  and  has  separated  (with  the  periosteum)  the 
external  lateral  and  annular  hgaments  and  some  part  of  the 
posterior  ligament. 

He  now  turns  to  the  humerus  and  pares  the  periosteum 
from  the  outer  part  of  the  olecranon  fossa,  and  continues  the 
peeling  process  until  he  has  bared  the  postero-external 
part  of  the  humerus  and  has  reached  the  external  condyle. 
The  elbow  is  now  a  little  flexed,  to  bring  this  process  better 
into  view,  and  it  is  stripped  entirely  of  its  periosteum,  and  of 
its  muscular  and  ligamentous  connections. 

With  the  periosteum  the  outer  part  of  the  posterior 
ligament  will  have  been  elevated  and  displaced  outwards. 

(c)  Decortication  of  the  Postero  -  internal  Parts.  —  The 
position  of  the  limb  is  now  changed.  The  hand  is  carried  up- 
wards beyond  the  head ;  the  arm  is  thus  close  to  the  face,  and 
the  hand,  which  is  supine,  is  beyond  the  upper  end  of  the  table. 
The  limb  is  extended,  and  the  cushion  again  supports  the 
elbow-joint.  The  wound  is  now  reversed,  and  the  inner  lip  is 
uppermost.  With  the  rugine  the  operator  bares  the  inner 
surface  of  the  olecranon,  clearing  off  the  rest  of  the  triceps 
and  of  the  posterior  ligament.  The  separation  is  carried  to 
the  inner  margin  of  the  articular  surface,  and  the  internal 
lateral  Hgament  is  thus  peeled  off  with  the  periosteum. 

The  postero-internal  surface  of  the  humerus,  including  the 
inner  part  of  the  olecranon  fossa  and  the  internal  condyle,  are 
now  laid  entirely  bare.  To  clear  the  condyle  the  joint  must 
be  a  little  flexed. 

((7)  Division  of  the  Humerus. — The  joint  can  now  be  dis- 
located, the  position  of  flexion  is  assumed,  and  the  lower  end 
of  the  humerus  is  made  to  protrude  in  the  wound.  The 
anterior  surface  of  the  bone,  including  the  coronoid  fossa,  is 
cleared  of  periosteum,  with  which  is  removed  also  the  anterior 
ligament  of  the  joint. 


640 


OPERATIVE    SUBGEBY. 


The  extremity  of  tlie  humerus,  being  now  entirely  bare,  is 
seized  with  lion  forceps  and  sawn  through. 

(e)  Division  of  the  Radius  and  Ulna. — It  only  now  remains 
to  clear  the  anterior  part  of  the  ulna,  including  the  coronoid 
process,  and  the  neck  of  the  radius,  and  to  saw  the  exposed 
bones  off,  mth  the  precautions  already  described  (Fig.  188). 

Comment — This  operation  is  admirable  in  theory,  but 
could  not  often  be  carried  out  in  its  entirety  in  practice.  In 
some  instances,  especially  in  excisions  for  injury  in  adults,  the 
decortication  would  be  practically  impos- 
sible. Especially  difficult  is  it  to  bare 
the  olecranon  and  coronoid  fossse  of  peri- 
osteum. In  many  cases  of  disease  it  would 
be  undesirable  to  save  the  implicated 
membrane. 

3.  Other  Forms  of  the  Operation. 
The  incision  most  usually  employed 
when  the  operation  was  first  introduced 
was  the  H-incision  ofMoreau  (Fig.  189,  b). 
This  was  the  incision  adopted  by 
S5rme,  Dupuytren,  and  many  others. 
Jaeger  and  Listen  used  the  same  incision, 
but  omitted  the  outer  vertical  limb  of 
the  H.  Roux  in  like  manner  omitted  the 
inner  vertical  limb  (Fig.  185,  a).  In  all  the 
early  operations  the  triceps  tendon  was 
cut  entirely  through. 

Subsequent  experience  has  condemned 
every  form  of  transverse  incision  in  this 
operation. 
Chassaignac  employed  a  longitudinal  posterior  cut  along 
the  outer  side  of  the  olecranon,  and  Langenbeck  a  like 
incision  along  the  inner  side.  These  incisions  rendered  the 
exposure  of  one  side  of  the  joint  very  easy,  and  the  la5dng 
bare  of  the  other  side  unduly  difficult.  They  are  inferior  to 
the  median  incision  above  described. 

Two  excellent  operations  by  means  of  lateral  incisions 
remain  to  be  described. 

Oilier  s  Operation  hy  the  Bayonet  Incision. — The  upper 
part   of  this   incision   is   vertical,    is    opposite    the    interval 


Fig.  189. — EXCISION  OF 

THE   ELBOW. 

A,  Oilier 's  incision ;  u 
H-shaped  incision  of 
Moreau. 


EXCISION  OF  ELBOW.  641 

between  the  triceps  and  the  supinator  longus,  is  commenced 
21  inches  above  the  joint-Une,  and  runs  down  to  the  tip  of 
the  outer  condyle. 

It  is  then  directed  obhquely  downwards  and  inwards 
to  the  base  of  tlie  olecranon,  and  is  finally  made  to  follow 
the  posterior  border  of  the  ulna  for  Ih  to  2  inches  (Fig. 
189,  A). 

A  vertical  incision  about  one  inch  in  length  is  made  over 
the  internal  condyle.  Through  this  small  lateral  incision  the 
point  of  the  condyle  is  bared,  and  the  attachment  of  the 
internal  hgament  separated. 

Turning  to  the  main  wound,  and  using  the  rugine  rather 
than  the  knife,  the  operator  decorticates  the  external  condyle, 
separating  the  external  lateral  ligament,  exposes  the  head  of 
the  radius,  detaches  the  triceps  tendon  together  with  the 
periosteum,  denudes  the  olecranon  and  the  margins  of  the 
sigmoid  cavity,  and  detaches  the  insertion  of  the  brachiaUs 
anticus. 

The  bones  of  the  forearm  are  now  luxated  forwards,  and 
are  divided  with  a  fine  saw. 

The  inner  segment  of  the  humerus  is  in  the  next  place 
freed  of  all  its  attachments,  and,  the  bone  being  now  bare,  the 
saw  is  appHed,  and  the  required  section  made. 

This  method  has  some  excellent  points.  It  is,  however, 
needlessly  complicated.  The  triceps  tendon  is  not  con- 
veniently exposed,  and  its  important  external  expansion  is 
divided.  The  ulnar  nerve  is  less  easily  dealt  with.  The 
wound  is  large,  and  not  well  adapted  for  drainage.  The  inner 
incision  is  inconveniently  placed,  and  may  cause  trouble  m 
the  after-treatment. 

Hiieter's  operation  is  a  modification  of  the  method  just 
described,  and  has  been  considered  as  especially  applicable  to 
cases  of  excision  for  anchylosis. 

The  operation  is  carried  out  in  the  following  steps  : — 

(a)  The  Ulnar  Incision  and  Clearing  of  the  Internal 
Condyle. — An  incision  one  inch  in  length  is  made  over  the 
internal  condjde  and  a  little  to  its  anterior  surface.  This  cut 
is  carried  to  the  bone,  and  with  a  rugine  and  elevator  the 
periosteum,  the  internal  lateral  Hgament,  and  the  united 
tendon  of  origin  of  the  flexor  muscles,  are  separated  fi'om  the 
p  p 


642 


OPERATIVE    SURGERY. 


bone.     The  joint  is  opened.     Care  must  be  taken  to  avcid  the 
uhiar  nerve. 

{h)  The  Radial  Incision  and  Resection  of  the  Head  of  the 
Radius. — The  arm  is  now  so  placed  as  to  bring  the  radial  side 
uppermost.  The  limb  is  fixed  upon  a  hard  cushion  in  the 
extended  position.  The  radial  cut  is  about  four  inches  in 
length.  It  skirts  the  outer  side  of  the  joint  on  its  posterior 
aspect. 

The  centre  of  the  incision  is  over  the  external  condyle, 
and  the  lower  part  of  it  over  the  radius  (Fig.  190).  With 
the  blunt  instruments  the  periosteum  is 
separated  from  the  outer  condyle,  together 
with  the  tendmous  attachments  and  the 
external  lateral  ligament.  The  orbicular 
ligament  is  divided  transversely,  and  the 
joint  is  opened  from  the  radial  side. 

The  head  of  the  radius  is  now  free, 
and  is  removed  by  means  of  a  keyhole  saw. 
(c)  The  Resection  of  the  Humerus. — The 
finger  is  introduced  into  the  joint  upon 
the  ulnar  side  while  the  elbow  is  flexed. 
The  hmits  of  the  anterior  part  of  the  cap- 
sule are  defined,  and  by  means  first  of  the 
knife  and  then  of  the  elevator  the  anterior 
surface  of  the  humerus  is  freed  as  far  as 
possible  both  of  periosteum  and  ligament. 

The  elbow  is  now  extended  and  the 
posterior  part  of  the  capsule  made  promi- 
nent, and  the  tissues  upon  this  side  are  in 
turn  peeled  from  the  bone.  The  lower  end 
of  the  humerus  should  by  this  time  be  bare, 
and,  the  forearm  being  adducted  {i.e.,  to  the  ulnar  side),  this 
extremity  of  bone  should  be  made  to  project  through  the 
radial  wound.  It  is  grasped  with  forceps  and  sawn  off.  The 
ulnar  nerve  should  not  be  seen. 

(cZ)  The  Resection  of  the  Olecranon. — The  olecranon  is 
readily  brought  into  view  in  the  radial  wound.  With  the 
nigine  it  is  stripped  of  periosteum,  and  is  freed  of  its 
connections  with  the  triceps  tendon.  The  upper  part  of  the 
ulna    and   the   coronoid  process   are   then   stripped  of  their 


Fig.   190.  —  EXCISION 

OF  THE  ELBOW  ; 
LATERAL  INCISIONS 
AS  USED  IN  EXCI- 
SION FOE  ANCHY- 
LOSIS. 


EXCISION  OF  ELBOW.  643 

coverings,  and  the  bono  is  sawn  through  just  above  the  base  of 
the  coronoid  process. 

This  operation  is  certainly  excellent,  and  has  yielded  very 
admirable  results  as  regards  the  function  of  the  joint.  The 
procedure  is  very  well  adapted  for  cases  of  excision  for 
anchylosis.  The  method  is  claimed  to  be  subperiosteal  For 
ordinary  purposes  Hueter's  operation  has  no  advantage  over 
the  median  dorsal  incision. 

After-treatment. — After  the  operation  the  limb  must  be 
placed  upon  a  suitable  splint,  and  the  bones  so  adjusted 
that  the  greater  diameters  of  the  bony  surfaces  correspond 
and  do  not  cross.  The  hand  should  be  in  the  mid-position 
between  pronation  and  supination,  and  the  elbow  be  very 
slightly  bent — so  sHghtly  that  the  forearm  will  be  nearer  to  the 
extended  posture  than  to  the  position  it  occupies  when  at 
right  angles  to  the  arm.  The  precise  angle  recommended  by 
most  surgeons  is  an  angle  of  135'^. 

Very  many  forms  of  splint  have  been  devised.  The  main 
requirements  of  such  appliances  are  that  they  be  light,  strong, 
rigid,  easily  kept  clean,  and  do  not  interfere  with  the  drainage 
and  dressing  of  the  wound. 

Mason's  splint  (Fig.  191)  answers  its  purpose  well,  and  also 
permits  the  joint  to  be  exercised  without  the  splint  being 
removed.  The  fingers  should  be  free.  The  splint  and  hmb 
may  be  at  first  suspended  from  a  cradle,  or  supported  upon  a 
pillow  with  sand-bags. 

It  must  be  borne  in  mind  that  there  is  some  disposition 
for  the  bones  of  the  forearm  to  be  displaced  backward,  that 
too  wide  a  distance  between  the  bones  may  lead  to  a  flail-like 
joint,  and  that  if,  on  the  other  hand,  the  sawn  surfaces  be 
kept  in  close  contact,  in  young  subjects  bony  anchylosis  may 
ensue. 

In  general  terms,  it  may  be  said  that  to  ensure  a  false  joint 
the  bones  should  be  separated  for  the  distance  of  half  an  inch. 

After  a  successful  excision  by  the  subperiosteal  method  in 
healthy  subjects  the  disposition  to  anchylosis  is  considerable. 
As  anchylosis  is  especially  to  be  feared  in  children,  the 
limb  may  be  put  up  from  the  first  on  a  right-angled  splint, 
such  as  that  recommended  for  the  purpose  by  Mr.  Jacobson 
(British  Medical  Journal,  vol.  i.,  1877,  page  774). 
p  p  2 


644  OPERATIVE    SUBOEBT. 

When  also  a  considerable  quantity  of  bone  has  been  re- 
moved, the  use,  from  the  commencement,  of  a  rectangular 
splint  is  advised  by  many. 

Passive  movements  of  the  linsers  and  shoulder,  and  flexion 
and  extension  of  the  wrist,  should  be  commenced  as  soon  as 
possible  after  the  operation— possibly  by  the  third  day — and 
should  be  persevered  with  daily.  Passive  movements  of  the 
elbow  may  be  commenced  about  the  tenth  day,  provided  that 
the  healing  process  has  proceeded  favourably,  and  the  measure 
can  be  borne  by  the  patient  without  undue  pain.  In  children 
such  movements  may  at  iirst  be  required  to  be  carried  out 
under  an  ansesthetic. 


Fig.  191. — mason's  splint  foe  excision  of  thk  elbow. 

* 

When  four  or  five  weeks  have  elapsed,  the  forearm  may  be 
gradually  brought  up  until  it  forms  a  right  angle  with  the 
arm.  At  the  end  of  six  or  eight  weeks  the  splint  may  be 
dispensed  "svith,  and  the  movements  of  the  elbow  should  be 
free.  Active  movements,  aided  by  massage  and  galvanism, 
should  now  be  advised ;  and  within  four  months  from  the  time 
of  the  operation  the  new  joint  should  have  acquired  solidity, 
and  be  capable  of  exhibiting  a  free  and  extensive  range  of 
movements. 

Results. — Excision  of  the  elbow  has  led  on  the  whole  to 
very  satisfactory  results,  and  in  a  large  proportion  of  the  more 
favourable  cases  the  results  have  been  most  admirable.  Even 
if  anchylosis  occurs  at  a  right  angle,  the  limb  is  in  a 
better  condition  than  it  was  while  the  seat  of  disease.  In 
the    more    unfortunate    instances    the    repair    is    imperfect 


I 


EXCISION  OF  ELBOW.  645 

for  one  reason  or  another,  and  a  very  loose  false  joint,  result- 
ing in  a  flail-like  limb,  is  the  final  production.  Even  in 
such  a  case  a  good  deal  may  be  done  by  means  of  a  suitable 
apparatus. 

"  In  my  experience,"  writes  Sir  Wilham  MacCormac,  "  the 
tendency  is  rather  to  anchylosis  than  to  increased  mobihty — 
at  least,  after  cases  excised  for  disease.  The  converse  may 
be  true  in  traumatic  cases." 

Ashhurst's  Tables  ("  Encyclopaedia  of  Surgery,"  1884,  vol 
iv.),  dealing  with  1,786  cases,  give  the  mortality  of  excision 
for  gunshot  wound  as  24'6,  for  other  injury  as  15'1,  and  for 
disease  as  10'6.  A  large  proportion  of  these  cases  are  not  of 
recent  date,  and  improved  methods  of  treating  wounds  have 
served  to  greatly  reduce  the  mortality. 


M& 


CHAPTER    XIII. 

Excision  of  the  Humerus. 

Portions  of  tlie  diaphysis  of  the  liumerus  have  been  ex- 
cised in  cases  of  compound  fracture,  of  bone  disease,  and  of 
new  growths.  The  most  successful  operations  of  this  kind 
have  been  performed  for  false  joint  after  fracture,  and  for 
badly-united  fracture.  In  gunshot  injuries  the  results  have 
not  been  favourable.  In  the  American  War  the  mortaUty 
attending  primary  excisions  of  portions  of  the  humerus  was 
30  per  cent.  (Otis). 

In  acute  necrosis  in  young  subjects  the  whole  diaphysis 
has  been  removed  subperiosteally  with  admirable  results,  the 
bone  having  been  restored  to  a  remarkable  degree. 

Langenbeck  excised  the  whole  of  the  humerus  in  a  man 
aged  20  for  necrosis  following  gunshot  wound.  A  mass  of 
new  bone  filled  the  j)lace  of  the  original  bone,  and  new  joints 
were  formed  at  the  shoulder  and  elbow.  Four  years  after  the 
operation  the  arm  on  the  side  operated  upon  was  found  to 
have  lost  only  3|  inches  in  length.  The  patient  could  execute 
many  movements,  although  the  Hmb  was  very  feeble. 

The  humerus  is  exposed  through  an  incision  made  upon 
the  outer  side  of  the  limb.  When  the  upper  part  of  tlie  shaft 
is  concerned,  the  cut  should  be  made  in  the  interval  between 
the  deltoid  and  the  pectoralis  major.  When  the  lower  part 
has  to  be  dealt  witli,  the  knife  should  follow  a  line  Avhich  is 
placed  over  the  insertion  of  the  deltoid,  and  along  the  ex- 
ternal intermuscular  septum.  The  first  care  of  the  operator 
should  be  to  seek  for  the  musculo-sjiiral  nerve,  which  is  care- 
fully isolated  and  drawn  aside.  The  bone  is  conveniently 
divided  with  a  chain-saw. 


647 


CHAPTER    XIV. 

Excision  of  the  Shoulder. 

The  operation  known  by  this  name  consists  really  of  an 
excision  of  the  upper  end  of  the  humerus.  The  shoulder- 
joint  is  not  excised — or,  in  other  words,  that  portion  of  the 
scapula  which  supports  the  glenoid  fossa  is  not  sawn  away 
with  the  articular  segment  of  the  humerus.  Portions  of  bone 
may  be  gouged  from  the  glenoid 
fossa,    but    more    than    that    is  /  ^ 

seldom  done.  The  operation  is 
comparatively  rarely  performed, 
and  the  conditions  under  which 
it  is  carried  out  are  the  same  as 
lead  to  excisions  of  other  joints. 
In  a  few  instances  the  upper 
end  of  the  humerus  has  been 
removed  for  a  new  growth. 

Excision  for  tubercular  joint 
disease  is — in  Great  Britain,  at 
least — exceedingly  rare. 

When  the  operation  is  per- 
formed, the  object  attained  is  the 
establishment  of  a  false  joint. 
The  luunerus  is  usually  divided  through  the  surgical  neck. 

In  this  excision  the  subperiosteal  method  is  especially  to 
be  advised. 

Excision  of  the  shoulder  was  first  performed  by  Bent,  of 
Newcastle,  in  1771  {Philosophical  Transactions,  vol.  Ixiv.,  jiage 
353,  1774).  Orred,  of  Chester,  performed  the  same  operation 
in  1778  {Ihicl,  vol.  Ixix.,  page  6,  1779).  In  1786  Moreau  the 
elder  excised  the  shoulder-joint,  literally  removing  not  only 
the  upper  end  of  the  humerus,  but  also  such  part  of  the 
scapula  as  supported  the  glenoid  fossa,  togethei-  Avith  part  of 
the  acromion. 


Fig.  192. — EXCISIOX  OF  THE 

shoulder;  moeeau's  squaee  flap. 


648  OPERATIVE    SUBGEUY. 

The  operation  was  warmly  supported  in  Great  Britain  by 
Syme,  with  whom  must  rest  the  credit  of  placing  this  pro- 
cedure among  the  recognised  operations  of  modern  surgery. 

In  the  early  operations  t':e  joint  was  exposed  by  raising  a 
flap  taken  from  the  deltoid  region. 

Bent  made  a  flap  with  the  base  internal,  employing  one 
vertical  and  two  transverse  incisions.  Moreau's  flap  had  its 
base  inferior  (Fig.  192),  while  the  flap  devised  by  Morel  had 

its  base  superior  (Fig.  193,  b). 
S3rme  employed  a  posterior 
flap  of  somewhat  large  size. 
Sabatier's  flap  was  V-shaped. 

The  flap  operations  have 
been  practically  abandoned. 
The  credit  of  introducing  the 
single  anterior  vertical  or 
oblique  incision  now  in  general 
use  is  ascribed  to  Baudens  and 
Malgaigne.  Orred,  it  may  be 
remarked,  had  used  a  longi- 
'  tudinal  incision  from  the  socket 
Fig.  193.— EXCISION  OF  THE  SHOTTLDEE.       of  tho  slioulder   to  tho   iusor- 

A,   Supra-acromial  incision  (Neudor-         fi'^m  /^-f  fV>o  /-loTtr>irl 
fer)  ;  B,  Morel's  rounded  flap.  ^^^"-  ^^  ^'^^  uenoiQ. 

Chassaignac  (1844)  appears 
to  have  been  the  first  surgeon  to  advise  that  the  biceps 
tendon  should  not  be  divided. 

The  perfection  of  the  subperiosteal  method  is  the  work  of 
Oilier. 

Neudorfer  employed  a  curved  incision  which,  starting  from 
the  spine  of  the  scapula,  passed  over  the  acromion  to  the 
coracoid  process.  The  acromion  was  sawn  through,  and  the 
head  of  the  bone  thrust  out  (Fig.  193,  a). 

Anatomical  Points. — The  shoulder-joint  is  very  simple  in 
its  construction,  and  the  bony  points  in  the  vicinity  of  the 
joint  are  easily  made  out.  The  part  of  the  humerus  felt 
beneath  the  deltoid  muscle  is  not  the  head,  but  the  tuberosi- 
ties— the  greater  tuberosity  externally,  the  lesser  in  front.  A 
considerable  portion  of  the  head  of  the  humerus  can  be  felt 
through  the  capsule  when  the  fingers  are  passed  high  up 
into    the  axilla,   and  the    limb    is    abducted.      The   head  of 


EXCISION  OF  SHOULDER. 


649 


the  bone  faces  very  much  in  the  direction  of  the  internal 
condyle. 

When  the  arm  hangs  at  the  side,  with  the  palm  forwards, 
the  bicipital  groove  looks  directly  forwards. 

The  position  of  the  coraco-acromial  ligament  may  be 
defined,  and  a  knife  thrust  through  the  middle  of  it  would 
strike  the  biceps  tendon  and 
open  the  shoulder-joint. 

The  groove  between  the 
pectoralis  major  and  deltoid 
muscles  is  usually  to  be  made 
out.  In  it  run  the  cephaHc 
vein  and  a  large  branch  of  the 
acromio-thoracic  artery.  Near 
the  gi'oove,  and  a  little  below 
the  clavicle,  the  coracoid  process 
may  be  felt.  The  process,  how- 
ever, does  not  actually  present 
in  the  interval  between  the  two 
muscles,  but  is  covered  by  the 
uppermost  fibres  of  the  deltoid. 

The  circumflex  nerve  and 
posterior  circumflex  artery  cross 
the  humerus  in  a  horizontal 
hue  that  is  about  a  finger's- 
breadth  above  the  centre  of 
the  deltoid  muscle,  as  measured  from  the  acromion  to  the 
deltoid  insertion.  The  artery  is  usually  above  the  nerve. 
The  point  at  which  these  structures  cross  the  humerus  about 
corresponds  to  the  surgical  neck. 

The  capsule  of  the  joint  is  very  lax,  and  is  attached  to  the 
humerus  along  the  line  of  the  anatomical  neck. 

The  line  of  the  epiphj'seal  cartilage  is  shown  in  Fig.  194. 
The  inner  part  of  the  cartilage  is  just  within  the  capsule,  the 
outer  anterior  and  posterior  parts  are  entirely  subperiosteal. 
The  epiphysis  is  united  with  the  shaft  at  about  the  age  of 
twenty  years. 

The  surgical  neck  is  situated  between  the  bases  of  the 
tuberosities  and  the  insertions  of  the  latissimus  dorsi,  teres 
major,  and  pectoralis  major  muscles  (Fig.  195). 


Fig.  194. — UPPER  i,;-..M,i  iiiKnxiMEEUS 
IN  A  SUBJECT  AGED  U).     {After  Oilier.) 

A,   Epiphysis ;  B,  Upper  part  of  cap- 
sule ;  c,  Lower  part  of  capsule. 


650 


OPERATIVE    SUBGEBY. 


To  the  greater  tuberosity  is  attached  the  supra-spinatus, 
infra-spinatus,  and  teres  minor  ;  to  the  lesser  process  the  sub- 
scapularis. 

1.  The  Operation  by  an  Anterior  Incision. 

The  method  here  described  is  the  "open  method."  The  sub- 
periosteal operation  is  dealt  Avith  in  the  section  which  follows. 

Operation. — The  patient  lies  upon  the  back,  close  to  the 
edsre  of  the  table,  Avith  the  shoulders  well  raised. 

The  elboAv  is  Hexed,  and  is  carried  a  little  from  the  side. 


The   assistant  who    holds  the 


Fig.  195. — DIAGRAM   OF    THE   TTPPEE  END 
OF    THE    HTJMKKUS. 

A,  Attachment  of  capsule  and  anatomical 
neck ;  B,  Line  of  epiphysis  ;  c,  Surgical 
neck  ;  8.s,  Supra-spinatus  ;  s.sc,  Sub- 
scapularis  ;  L.D,  Latissimus  dorsi ; 
P.M,  Pectoralis  major ;  t.m,  Teres 
major. 


limb  sits  or  stands  by  the 
patient's  loins.  The  surgeon 
takes  up  a  position  to  the 
outer  side  of  the  shoulder  and 
faces  the  subject.  A  second 
assistant  stands  behind  the 
shoulder,  facing  the  operator. 
The  bony  points  about  the 
joint  should  be  defined. 

{a)  The  Incision. — The  in- 
cision, Avhich  is  three  and  a 
half  to  four  inches  in  length, 
commences  at  the  outer  side 
of  the  tip  of  the  coracoid  pro- 
cess, and  is  carried  downwards 
and  a  little  outwards  to  follow 
the  inclination  of  the  anterior 
margin  of  the  deltoid  muscle 
(Fig.  196,  A). 

The  knife  is  carried  straight 


down  to  the  joint,  the  coraco- 
acromial  arch  is  exposed,  and 
the  capsule  of  the  joint  laid  bare  in  the  line  of  the  incision. 
The  biceps  tendon  is  next  sought  for,  and  the  capsular  hga- 
mcnt  is  opened  vertically  just  to  the  outer  side  of  the  tendon. 
It  is  most  conveniently  incised  from  below  upwards. 

(6)  The  Separation  of  the  Outer  Margin  of  the  Wound. — 
The  operator  now  proceeds  to  clear  the  tissues  from  the  bone 
ui)on  the  outer  side  of  the  wound.  In  the  case  of  the  right 
limb  this  will  be  the  left  margin  of  the  wound,  and  in  the  case 
of  the  left  limb  tlic  riLrht  maryin. 


EXCISION  OF  SHOULDER.  fiol 

The  parts  are  well  retracted  with  the  left  thumb,  aided 
when  required  by  retractors.  The  surgeon  uses  a  blunt- 
pointed  knife,  and  separates  the  soft  parts  from  the  upper  end 
of  the  humerus  by  cutting-  on  to  the  bone. 

The  instrument  should  be  kept  as  close  to  the  bone  as 
possible.  As  the  separation  proceeds,  the  assistant  rotates  the 
humerus  inwards,  while  at  the  same  time  he  depresses  the 
elbow,  and  forces  the  head  of  the  bone  forwards. 

The  surgeon  clears  the  capsule  from  the  outer  part  of  the 
b(me,  and  on  reachinsf  the  external  tuberosity  severs  the  in- 
sertions  of  the  supra-spinatus,  infra-spinatus,  and  small  teres 
muscles. 

The  second  assistant  aids  in  retracting  the  soft  parts. 

(c)  The  Separation  of  the  Inner  Margin  of  the  Wound. — 
The  limb  is  restored  to  the  position  it  originally  occupied,  and 
the  surgeon  proceeds  to  clear  the  bone  upon  its  inner  as23ect 
in  the  manner  just  described.  The  humerus  is  rotated  out- 
wards as  he  proceeds  ;  and  when  the  lesser  tuberosity  is  reached, 
the  subscapularis  insertion  is  divided  and  the  attachment  of 
the  capsule  beyond  it. 

In  this  stage  care  must  be  taken  of  the  biceps  tendon, 
which  should  be  drawn  aside. 

(d)  The  Clearing  of  the  Neck  of  the  Bone. — The  biceps 
tendon  is  displaced  inwards.  The  elbow  is  flexed,  and  the  arm 
is  held  vertically  (i.e.,  at  right  angles  to  the  table),  and  is 
thrust  upwards  so  that  the  head  of  the  bone  is  made  to  project 
through  the  wound.  The  posterior  part  of  the  neck  of  the  bone 
is  cleared,  and  the  parts  prepared  for  the  passage  of  the  saw. 

(e)  The  Excision  of  the  Head  of  the  Humerus. — The  head  of 
the  bone  is  seized  with  lion  forceps  held  in  the  surgeon's  left 
hand,  and  the  bone  is  sawn  through  with  either  a  small 
Butcher's  saw  or  a  thin  saw  Avith  a  movable  back.  The  saw- 
cut  should  incline  from  witln^ut  very  slightly  downwards  and 
inwards,  so  that  no  sharp  end  may  be  left  Avhich  might  press 
upon  the  axillary  vessels  or  nerves. 

In  sawiucr  the  left  humerus  the  surq-eon  stands  facingf  the 
patient,  in  dealing  with  the  right  he  will  find  it  more  con- 
venient to  stand  behind  the  shoulder  (by  the  patient's  head). 
While  the  saw  is  being  used,  the  soft  parts  iiuist  be  protected 
by  metal  spatulai. 


652 


OPERATIVE    SUEGEBY. 


(/)  The  glenoid  cavity  is  examined,  a  coimter-pimcture  for 
drainage  is  made  at  tlae  posterior  and  inferior  part  of  the 
wound,  the  skin  incision  is  closed  with  sutures,  and  the  limb 
placed  in  position. 

Comment. — This  procedure  can  claim  to  be  the  best  and 
the  most  generally-adopted  method  of  excising  the  shoulder. 

The  capsule  is  readily  reached,  the  biceps  tendon  is  easily 
dealt  with  and  protected  fi-om  hurt,  and  no  injury  is  inflicted 

upon    the    most    important 
I  -  muscle  of  the  shoulder — the 

■^'  deltoid.     The  wound  is   not 

^  well  adapted  for  drainage,  a 

defect  met  by  the  counter- 
puncture  just  described. 
The  incision  described  is 
that  of  Baudens,  Hueter,  and 
OUier. 

Langenbeck's  incision  is 
placed  more  to  the  outer 
side,  and  has  for  its  start- 
ing-point the  acromio-clavi- 
cular  jomt  (Fig.  196,  b).  No 
especial  advantage  apj^ears 
to  have  been  claimed  for  a 
skin  wound  so  placed,  while 
it  has  the  disadvantage' 
of  inflicting  more  serious 
flainagc  upon  the  deltoid  muscle. 

In  operating  upon  the  left  side  it  may  be  more  convenient 
to  clear  the  left  side  of  the  wound  first. 

As  little  bone  should  be  removed  as  is  possible.  In  some 
instances  it  may  be  practicable  to  make  the  section  at  the 
anatomical  neck.  It  will  obviously  be  a  great  gain  if  either  of 
the  tuberosities  can  be  saved.  The  hit^her  the  saw-cut,  the 
wider  the  section.   . 

In  children  only  very  little  of  the  bone  can  be  removed 
without  taking  aAvay  the  whole  of  the  epijohysis. 

So  far  as  the  growth  of  the  arm  is  c  jncerned,  this  is  the 
most  important  epiphysis  in  the  limb. 

Some  surgeons  have  advised  that  the  bone  be  sawn  in 


Fig.     196. — EXCISION    OF    THE    SHOTTLDER. 

A,  Incisions  of  Baudens,  Hueter,  and 
Oilier  ;  i',  Vertical  incision  of  Langen- 
beck  and  others ;  c,  Morel's  incision. 


EXCISION  OF  SHOULDER.  653 

situ — i.e.,  that  the  head  be  not  protruded  through  the  wound. 
This  method,  hoAvever,  is  less  precise,  Httle  opportunity  is 
given  of  fully  examining  the  part,  and  the  tissues  around 
may  be  damaged  by  the  saw.  If  the  bone  be  divided  in  situ, 
a  chain-saw  should  be  employed. 

2.  The  Subperiosteal  Operation. 

The  patient  is  placed  in  the  same  position  as  in  the  last 
operation.  The  arm  lies  by  the  side.  The  same  incision 
is  made.  The  capsule  is  exposed,  and  the  biceps  tendon  dis- 
covered. 

The  capsule  is  incised  vertically  to  the  outer  side  of  the 
biceps  tendon,  and  the  incision  is  carried  downwards  through 
the  periosteum  on  the  neck  of  the  bone  as  far  as  the  intended 
saw-cut.  The  knife  is  now  laid  aside  for  the  rugine  and 
elevator.  Commencing  at  the  outer  segment  of  the  wound,  the 
surgeon  separates  all  the  soft  parts  from  the  bone,  detaching 
the  periosteum,  the  cajDSular  ligament,  and  the  muscular  inser- 
tions in  one  continuous  and  unbroken  layer.  The  rugine  is 
worked  upwards  and  downwards.  The  arm  is  rotated  inwards 
graduall}^,  and  is  at  the  same  time  abducted,  and  the  head  of 
the  bone  pushed  upwards  and  forAvards.  The  greater  tuberosity 
is  reached  and  cleared,  and  the  bone  fi'eed  as  far  as  possible 
beyond  it.  In  clearing  the  outer  part  of  the  humerus,  the 
surgeon  should  stand  facing  the  patient  while  dealing  with  the 
risrht  Hmb,  and  behind  the  shoulder — i.e.,  close  to  the  head — 
Avhile  treating  the  left  hmb. 

In  the  process  the  thumb  and  suitable  steel  retractors 
must  be  vigorously  employed  to  draw  back  the  separated 
tissues. 

The  next  step  consists  of  clearing  the  lesser  tuberosity,  and 
the  inner  part  of  the  neck  of  the  bone.  Like  measures  are 
adopted.  As  the  surgeon  progresses,  the  limb  is  rotated  out- 
wards, the  arm  is  adducted,  and  the  head  of  the  humerus  is 
thrust  upwards  and  forwards. 

In  this  part  of  the  operation  the  surgeon  stands  facing 
the  patient  when  excising  the  left  bone,  and  behind  the 
shoulder  when  operating  upon  the  right  side. 

The  head  of  the  bone  is  now  thrust  out  of  the  wound,  and 
the  neck  is  cleared  of  any  remaining  ligamentous  or  periosteal 
attachments. 


654  OPERATIVE    SURGERY. 

The  excision  of  the  head  is  carried  out  in  the  manner 
ah-eady  described. 

Com7)ient. — This  operation  ditfers  from  the  last  only 
in  the  essential  particular  that  the  bone  is  laid  entirely 
bare. 

The  method  is  of  course  not  always  practicable,  and  some- 
times not  advisable  ;  but  whenever  it  is  possible,  it  should  be 
carried  out.  The  results  which  have  been  obtained  by  the 
subperiosteal  method  are  infinitely  superior,  so  far  as  function 
is  concerned,  to  those  which  follow  the  open  method.  The 
attachments  of  the  rotator  muscles  are  saved,  and  the 
continuity  of  the  capsule  Avith  the  periosteum  of  the  shaft  of 
the  bone  is  preserved.  The  actual  amount  of  periosteum  saved 
is  not  considerable. 

3.  Other  Methods. 

1.  The  Deltoid  Flap. — The  chief  form^  of  deltoid  flap  which 
have  been  from  time  to  time  made  use  of,  have  been  already 
described  in  the  introductory  paragraphs.  This  form  of  opera- 
tion would  appear  to  be  now  abandoned.  It  has  the  advan- 
tages of  being  easy  of  performance,  and  of  well  exposing  the 
parts  of  the  joint.  It  has  the  overwhelming  disadvantage  of 
destroying  the  function  of  the  deltoid  muscle.  It  is  conceiv- 
able that  the  operation  might  still  be  carried  out  in  some  cases 
of  new  growth,  e.g.,  a  large  enchondroma  involving  the  upper 
end  of  the  bone,  for  the  removal  of  which  considerable  space 
would  be  required. 

2.  T?ie  Posterior  Incision. — Sir  William  MacCormac  con- 
siders that  this  method  may  be  carried  out  when  it  is  not 
necessary  to  divide  the  bone  below  the  tuberosities,  and 
describes  the  operation  in  the  following  words  : — 

"  The  patient  must  be  placed  on  the  sound  side,  the  arm 
ficxod  at  the  elbow,  somewhat  abducted  and  rotated  outwards, 
so  that  the  external  condyle  looks  backwards.  This  brings  the 
middle  of  the  great  tuberosity  into  the  line  of  the  wound.  A 
vertical  incision  is  then  made  downwards  for  about  four  inches 
from  the  prominent  angular  projection  so  plainly  felt  on  the 
inferior  margin  of  the  acromion  (Fig.  197).  The  posterior 
part  of  the  deltoid  is  divided,  and  the  knife  at  once  sunk  into 
the  capsule  beneath  the  acromion.  The  great  tuberosity  and 
the  bicipital  groove  just  in  front  of  it  may  now  be  brought- 


EXCISION  OF  SHOULDER. 


655 


within  the  area  of  the  wonnd,  and  the  muscles  attached  to  the 
tuberosity  can  be  separated.  The  rotation  outwards  of  the  arm 
being  continued,  the  elevator  is  used  to  raise  the  periosteum 
and  capsule  till  the  bicipital  groove  is  reached,  when  the 
biceps  tendon  is  dislodged.  Then  the  arm  must  be  strongly- 
rotated  inwards,  and  the  subscapularis  muscle  at  its  insertion 
will  come  into  view.  This  is  separated  in  a  similar  manner 
from  the  lesser  tuberosity.  The  head  may  now  be  made  to 
project  from  the  wound,  and  by  rotating  alternately  outwards 
and  inwards  any  remaining  soft  parts  or  capsule  may  be 
divided  on  the  anterior  and  axillary  margins  of  the  wound,  the 
head  fully  luxated  and  removed.  The  trunk  of  the  circumflex 
nerve  will  in  this  case  be  cut 
through,  and  no  active  abduction 
can  afterwards  be  expected. 
Through  the  posterior  incision 
the  glenoid  cavity,  if  need  be, 
can  be  much  more  easily  re- 
moved than  through  the  anterior 
wound." 

Except  in  so  far  that  good 
drainage  is  provided  for,  and 
that  the  glenoid  process  can  be 
more  readily  dealt  with,  this 
operation  is  in  every  way  in- 
ferior to  the  method  by  the 
anterior  incision. 

After-treatment.  —  The  up- 
per end  of  the  humerus  is  to  be 
brought  into   contact  with   the 

glenoid  fossa.  The  arm  is  secured  to  the  side,  the  hand 
rests  in  a  sling.  A  large  pad  of  cotton-wool  is  introduced 
into  the  axilla.  This  pad  is  intended  to  support  the  bone, 
to  assist  in  fixing  the  parts,  and  to  counteract  the  tend- 
ency which  will  be  exhibited  for  the  upper  end  of  the 
humerus  to  be  drawn  inwards  under  the  coracoid  process. 
This  displacement  is  especially  apt  to  occur  when  the 
external  rotator  muscles  have  been  divided,  and  there  is 
little  to  withstand  the  action  of  the  pectoralis  major  and 
latissimus   dorsi.     The   size   of  the   pad  must   be   regidated 


Fig. 


197. — EXCISION    OF    SHOULDEE  : 
POSTEEIOR  INCISION. 


€56  OPERATIVE    SUBGEBY. 

according  to  the  needs  of  the  case.  It  should  be  of  triangular 
outline,  with  the  base  uppermost. 

The  pad  is  likely  to  fail,  if  it  fail  at  all,  from  being  too 
small  rather  than  too  large.     No  sphnt  is  required. 

Passive  movements  of  the  fingers,  wrist,  and  elbow,  ma}'^  be 
commenced  within  a  day  or  two  of  the  operation.  Very  gentle 
passive  movements  of  the  shoulder  may  be  first  attempted  at 
the  end  of  some  fourteen  days.  These  movements  should 
consist  of  flexion  and  extension,  of  slight  rotation,  and  of  still 
sHghter  abduction.  The  latter  position  tends  to  throw  the 
end  of  the  bone  inwards — or,  rather,  to  assist  the  disposition  to 
that  deviation.  Massage,  electricity,  and  active  movements  will 
follow  in  due  course.  The  arm  may  be  allowed  to  hang,  with 
no  other  support  than  a  shng,  at  the  end  of  some  four  or  five 
weeks. 

Results.— The  results  of  this  operation  may  be  considered 
to  be  very  satisfactory.  Culbertson,  dealing  with  115  cases  oi 
excision  for  disease,  shows  that  the  mortality  has  been  onl}) 
18-2  per  cent.,  a  result  which  compares  very  favourably  with 
the  mortality  after  amputation  at  the  shoulder-joint. 

There  is  no  doubt  that  increasing  care  in  the  selection  of 
cases,  and  more  precise  measures  for  treating  wounds,  have 
led  to  a  substantial  reduction  in  the  mortality  as  given  by  Cul- 
bertson in  1876.  More  than  two-thirds  of  the  subjects  of 
the  operation  appear  to  recover,  with  quite  useful  limbs. 
In  many  instances  the  restoration  of  function  has  been 
remarkable.  As  a  rule  flexion  and  extension  are  freely  per- 
formed, and  the  patient  can  hft  considerable  weights. 

Adduction  also  is  well  accomplished.  On  the  other  hand, 
rotation  movements  and  abduction  are  feebly  performed. 

The  arm  cannot  be  lifted  beyond  a  right  angle  with  the 
trunk.  It  is  after  the  subperiosteal  operations  that  the  best 
results  have  been  obtained,  and  some  of  (Jllier's  cases  show  a 
very  remarkable  restoration  of  function. 

There  is  a  tendency,  as  already  stated,  for  the  upper  end 
f)f  tlic  bone  to  assume  the  position  occu})ied  by  the  head  in 
sub-coracoid  dislocation.  Anch}iosis  ap})ears  to  result  more 
fi-equcntly  than  a  flail-like  joint. 


657 


CHAPTER    XV. 
Excision  of  the  Clavicle  and  Scapula. 

the  clavicle. 

The  clavicle  has  frequently  been  removed  in  whole  or  in 
part.  The  conditions  for  which  the  operation  has  been  per- 
formed are  caries,  necrosis,  tumour,  severe  injury  {e.g.,  gun- 
shot wound),  and  irreducible  dislocation  of  the  inner  end  of 
the  bone,  causing  pressure  symptoms. 

The  first  operation  for  the  complete  removal  of  the  clavicle 
appears  to  have  been  perfonned  by  McCreary,  of  Kentucky,  in 
1811,  for  necrosis  (Johnson,  Med.  and  Surg.  Journ.,  vol.  vi., 
page  474,  1850). 

Anatomical  Points. — The  general  anatomy  of  the  clavicle 
need  not  be  given  in  detail  in  this  place. 

The  bone  is  sujjerlicial,  and  is  crossed  in  fi'ont  by  the 
supra-clavicular  nerves,  and  a  small  vein  which  connects  the 
cephahc  Avith  the  external  jugTilar. 

The  main  ligaments  that  hold  the  bone  in  place  are  the 
conoid,  the  trapezoid,  the  rhomboid,  and  the  inter-clavicular. 

The  extent  of  the  attachment  of  the  great  muscles — the 
deltoid,  the  trapezius,  the  pectoralis  major,  and  the  sterno- 
mastoid — must  be  borne  in  mind. 

The  two  curves  of  the  bone  meet  at  the  junction  of  the 
middle  with  the  outer  third,  and  it  is  here  that  the  bone  is 
the  most  slender. 

The  clavicle  begins  to  ossify  before  an}'  long  bone  in  the 
body,  and  at  birth  the  entire  shaft  is  bony,  the  two  ends  being 
still  cartilaginous.  There  is  one  ejjiphysis — a  mere  shell — for  the 
sternal  end.  It  appears  between  the  eighteenth  and  twentieth 
years,  and  joins  the  shaft  at  twenty-five. 

Beneath  the  clavicle  the  great  vessels  and  the  great  nerve- 
cords  lie  upon  the  first  rib.      The  vein  is  the  most  internal, 


658  OPERATIVE    SURGE  BY. 

and  occupies  the  acute  angle  between  the  collar-bone  and  the 
first  rib.  Between  these  structures  and  the  bone  is  interposed 
the  subclavius  muscle  and  the  dense  fascia  which  surrounds 
it.  This  muscle  is  of  great  service  in  the  operation,  and 
affords  a  substantial  protection  to  the  parts  beneath. 

Behind  the  clavicle  the  following  structures  may  be  noted: — 
The  innominate,  subclavian,  and  external  jugular  veins  ;  the 
subclavian,  supra-scapular,  and  internal  mammary  arteries  ; 
the  cords  of  the  brachial  plexus  ;  the  phrenic  nerve  and  nerve 
of  Bell ;  the  thoracic  duct ;  the  omo-hyoid,  scalene,  sterno- 
hyoid, and  sterno-thyroid  muscles  ;  the  pleura  and  the  apex 
of  the  lung. 

Operation. — The  patient  is  placed  in  the  position  advised 
in  ligaturing  the  third  part  of  the  subclavian  artery,  and  the 
surs^eon  stands  upon  the  affected  side.  The  excision  knife 
should  be  small  and  blunt-pointed. 

An  incision  is  made  along  the  whole  length  of  the  bone — 
when  entire  excision  is  intended — and  extends  beyond  it 
over  the  sterno-clavicular  and  acromio-clavicular  joints. 

The  bone  is  carefully  cleared  of  all  its  soft  parts  upon  the 
superior  and  anterior  aspects. 

If  the  case  be  suited  for  tlie  subperiosteal  method,  the 
rugine  may  be  employed  to  lay  the  bone  bare. 

A  way  should  be  made  immediately  behind  the  bone  at 
the  junction  of  the  outer  with  the  middle  thirds,  and  at  this 
point  a  chain-saw  should  be  passed  around  the  clavicle  with 
the  usual  precautions. 

AVhen  the  bone  has  been  divided,  the  inner  end  of  the 
acromial  segment  is  seized  with  hon  forceps,  and  is  drawn 
forwards  with  the  left  hand,  while  with  the  right  the  surgeon 
clears  it  upon  its  inferior  and  posterior  aspects.  When  the 
acromial  part  has  been  removed,  the  sternal  segment  is  seized 
and  dealt  with  in  hke  manner.  It  is  the  removal  of  this 
portion  of  the  bone  that  involves  the  chief  element  of  risk  in 
the  operation. 

Throughout  the  whole  of  the  excision  the  greatest  care 
must  be  taken  to  keep  the  knife  close  to  the  bone,  to  cut 
always  on  the  bone,  to  be  equally  cautious  with  the  rugine, 
and  to  use  spatulse  and  retractors,  so  as  to  protect  the  soft 
parts  in  the  event  of  the  instrument  slipping. 


EXCISION  OF  CLAVICLE.  659 

After  the  excision  the  wound  is  closed  with  sutures,  and 
the  limb  is  adjusted  as  in  the  treatment  of  fracture  of  the 
clavicle. 

Comment. — The  above  description  can  give  little  idea  of 
this  excision,  and  an  operation  upon  the  cadaver  can  afford 
little  conception  of  the  procedure  as  it  is  carried  out  in 
practice. 

In  dealing  with  the  living  subject  the  parts  will  be  so 
modified  and  disturbed  by  injury  or  disease  that  the  lines  of 
a  formal  operation  cannot  be  recognised. 

Those  who  have  carried  out  excision  of  the  clavicle  only  on 
the  cadaver  can  hardly  realise  that  in  Mott's  well-known  case 
the  operation  occupied  four  hours,  and  over  thirty  ligatures 
were  applied.  The  patient  was  a  lad  of  nineteen,  and  the 
excision  was  for  a  new  growth.  An  excellent  recovery 
resulted  {Amer.  Journ.  Med.  Sci.,  vol.  iii.,  O.S.,  page  100, 
1828). 

The  operation  is  usually  attended  with  much  bleeding  ; 
and  the  nearer  the  subj)eriosteal  method  can  be  adhered  to 
the  less  will  this  be  in  amount. 

The  large  veins  in  the  vicinity  of  the  bone  are  exposed  to 
great  risk,  and  have  been  both  wounded  and  torn.  Another 
great  danger  depends  upon  the  entrance  of  air  into  divided 
veins. 

There  is  risk  of  wounding  the  pleura,  of  tearing  the 
thoracic  duct,  and  of  injuring  some  of  the  important  nerves 
which  are  close  to  the  sternal  end  of  the  bone. 

A  key-saw  may  be  used  in  the  place  of  the  chain-saw. 

Results. — Ashhurst  has  collected  28  examples  of  excision 
of  the  entire  clavicle.  The  operation  was  performed  16  times 
for  caries  or  necrosis,  9  times  for  tumour,  and  3  times  for 
injury.     Six  patients  died,  and  22  recovered. 

Among  74  examples  of  partial  excision  of  the  bone,  only 
10  deaths  are  recorded. 

THE    SCAPULA. 

In  the  larger  number  of  cases  of  excision  of  this  bone  the 
operation  has  been  performed  for  tumour.     Excision  has  also 
been  carried  out  in  the  treatment  of  caries  or  necrosis,  and  for 
severe  injur}^ 
Q  Q  2 


660  OPERATIVE    SURGERY. 

In  the  greater  proportion  of  the  instances  the  excision  has 
been  partial 

Partial  excisions,  such  as  concern  the  removal  of  the  acro- 
mion, or  of  portions  of  the  spine  for  necrosis,  hardly  come 
under  the  present  category.  These  operations  involve  little 
more  than  the  removal  of  sequestra. 

Listen  in  1819  removed  about  three-fourths  of  the  scapula 
for  tumour,  leaving  the  glenoid  cavity  and  the  processes 
(•'  Elements  of  Surgery,"  2nd  ed.,  page  190). 

Luke  in  1828  performed  an  operation  of  like  magnitude, 
also  for  tumour  (Lond.  Med.  Gaz.,  1830,  vol.  v.). 

The  first  operation  for  the  removal  of  the  entire  bone  is 
ascribed  to  Langenbeck  in  1855  (Deutsche  Klinik,  1855). 

Anatomical  Points. — The  precise  attachment  of  the  various 
scapular  muscles  must  be  borne  in  mind. 

It  is  well  to  note  also  the  dense  fascia  which  covers  and 
binds  down  the  muscles  of  the  supra-spinous  and  infra-spinous 
regions. 

The  exact  attachments  of  the  capsular  ligament,  of  the 
<;onoid  and  trapezoid  ligaments,  and  of  the  coraco-humeral 
ligament,  are  material  to  this  operation. 

The  importance  of  saving  the  glenoid  segment  of  the 
bone,  and  the  acromion  and  coracoid  processes  will  be  obvious. 

A  line  drawn  from  the  supra-scapular  notch  through  the 
great  scapular  notch  marks  the  site  of  the  surgical  neck  of 
the  bone,  and  isolates  the  glenoid  cavity  and  coracoid  process. 
The  periosteum  is  thick  and  strong  over  the  spine,  the  acro- 
mion and  coracoid  processes,  and  along  the  borders. 

The  epiphysis  which  forms  the  acromion  joins  the  main 
bone  at  nineteen ;  that  which  forms  the  coracoid,  at  about 
fourteen. 

Nutrient  branches  from  the  subscapular  artery  pierce  the 
concave  surface  of  the  bone,  while  like  vessels  from  the  supra- 
scapular artery  enter  foramina  in  both  the  supra-spinous  and 
infra-spinous  fossae. 

The  main  vessels  to  be  noted  in  connection  with  the 
operation  are — (1)  the  supra-scapular,  at  the  superior  border 
<){  the  bone,  where  it  crosses  over  the  ligament  of  the  supra- 
scapular notch  ;  (2)  the  posterior  scapular,  which  follows  the 
vertebral  border  of  the  bone  under  cover  of  the  rhomboids ; 


EXCISION  OF  SCAPULA.  661 

(3)  the  subscapular,  which  runs  along  the  lower  border  of  the 
subscapularis  muscle  to  reach  the  inferior  angle ;  (4)  the 
dorsahs  scapulie,  which  crosses  the  axillary  border  of  the  bone 
to  enter  the  infra-spinous  fossa  ;  and  (5)  the  acromial  branches 
of  the  acromio-thoracic  artery  which  ramify  about  the  acromion 
process. 

The  largest  of  these  vessels  are  the  dorsalis  scapulae  and 
the  subscapular.  The  former  vessel  crosses  the  axillary 
border  of  the  scapula  at  a  point  on  a  level  with  the  centre  of 
the  vertical  axis  of  the  deltoid  muscle. 

Operation. — The  patient  lies  close  to  the  edge  of  the  table, 
and  upon  the  sound  side.  The  back  of  the  scapula  is  well 
exposed.  The  following  incisions  are  made : — One  follows  the 
vertebral  border  of  the  bone  from  the  superior  to  the  inferior 
angle ;  it  is  to  the  outer  side  of  the  border,  and  is  parallel 
with  it.  A  second  incision  commences  over  the  acromio- 
clavicular joint,  and  is  carried  along  the  acromion  and  spine  to 
meet  the  first  incision  at  a  right  angle. 

Two  flaps  are  thus  formed — an  upper  and  a  lower  one. 
The  operation  is  carried  out  in  the  following  steps : — 

1.  The  upper  flap  is  first  turned  up,  and  the  trapezius 
muscle  is  divided  along  its  line  of  attachment  to  the  bone. 

2.  The  lower  flap  is  turned  down,  and  the  deltoid  muscle 
is  in  like  manner  divided  at  its  insertion. 

3.  The  patient's  hand  is  drawn  as  far  as  possible  over  the 
shoulder  of  the  sound  side,  to  bring  into  prominence  the 
vertebral  border. 

All  the  muscles  attached  to  this  border  are  severed  close 
to  the  bone.     The  posterior  scapular  artery  is  ligatured. 

The  free  edge  of  the  scapula  is  dragged  towards  the 
operator,  and  the  serratus  magnus  is  cut  through. 

4.  While  the  limb  is  still  in  the  same  position  the 
superior  border  of  the  bone  is  cleared  and  the  supra-scapular 
artery  is  ligatured. 

5.  The  patient's  hand  is  now  dragged  down  towards  the 
hip.  The  acromio-clavicular  joint  is  opened.  Any  remaining 
attachments  of  the  deltoid  and  trapezius  are  divided.  The 
conoid  and  trapezoid  ligaments  are  cut  fi'om  behind,  close  to 
the  clavicle. 

The  limb  is  so  manipulated  that  the  coracoid  process  is 


662  OPEBATIVE    SURGERY.     ' 

turned  towards  the  operator.  The  muscles  attached  to  it 
(biceps,  coraco-brachiahs,  pectoralis  minor)  and  the  remaining 
hgamentous  fibres  are  divided. 

G.  The  capsule  is  divided  with  the  muscles  around  it, 
viz.,  the  supra-spinatus,  infra-spmatus,  and  subscapularis.  The 
scapular  heads  of  the  biceps  and  triceps  are  cut.  The  bone  is 
now  only  connected  by  means  of  its  axillary  border. 

7.  The  muscles  of  the  axillary  border — the  teres  major 
and  minor — are  divided  near  to  the  scapula. 

The  subscapular  artery  is  sought  for  and  ligatured. 

The  scapula  is  at  this  last  stage  in  such  a  position  that  the 
muscles  may  be  cut  from  before  backwards,  and  the  trunk 
of  the  subscapular  artery  may  be  exposed  before  it  gives  off 
the  dorsahs  scapulas. 

Gom^nient. — The  steps  of  the  operation  need  not  follow  the 
above  course,  but  may  be  varied  as  found  most  convenient. 
It  is  very  desirable,  however,  that  the  muscles  of  the  axillary 
border,  and  the  subscapular  artery,  should  be  left  to  the  last. 

The  great  risk  throughout  the  operation  is  from 
hgemorrhage ;  and  as  the  excision  is  most  usually  carried 
out  for  a  sarcomatous  growth,  the  vessels  are  numerous  and  of 
large  size.  It  is  essential  that  compression  of  the  subclavian 
artery  be  maintained,  and,  if  necessary,  a  special  incision  may 
be  made  over  that  vessel  in  order  that  it  may  be  more 
conveniently  reached. 

The  main  vessels  may  be  exposed  and  ligatured  before 
they  are  cut.  The  other  bleeding  arteries  must  be  clamped  as 
divided. 

"  ]  )ivision  of  the  clavicle,"  writes  MacCormac,  "  with  a 
small  saw  just  internal  to  the  conoid  ligament  increases  the 
facihty  with  which  the  later  steps  of  the  operation  may  be 
completed,  for  then  time  is  not  lost  in  detaching  the  outer 
extremity  of  the  clavicle  from  its  connections  with  the 
scapula." 

It  is  assumed  in  the  above  description  that  the  operation 
is  perfoi-med  for  tumour,  and  consequently  the  deeper 
muscles  of  the  scapula — namely,  the  subscapularis,  supra- 
S[»inatus,  and  infra-spinatus — are  removed  with  the  bone,  their 
tendons  of  insertion  alone  being  left. 

The  subperiosteal  method  has  been  advised  in  performing 


EXCISION  OF  SCAPULA.  663 

this  excision.  It  may  possibly  be  carried  out  when  dealing  with 
some  small  portion  of  the  bone — as  when  the  operation  is 
performed  for  limited  necrosis  or  caries — but  in  the  great 
majority  of  instances,  and  certainly  in  all  operations  for 
tumour,  the  method  is  entirely  out  of  place. 

The  procedure  is  slow  and  tedious,  and  enormous  masses 
of  quite  useless  muscle  are  left  attached  to  the  humerus.  If 
the  excision  be  for  a  growth,  the  more  completely  the  bone  is 
removed  the  better. 

Mr.  PoUock  (St.  Georf/e's  Hospital  Rej)orts,  vol.  iv., 
page  236)  has  pointed  out  that  in  dealing  with  cases  of  ncAv 
growth  the  removal  of  a  part  of  the  scapula  is  a  less 
satisfactory  proceeding  than  the  removal  of  the  whole. 

"  If  a  portion  of  the  scapula  be  removed,  it  should  only  be 
the  lower  portion.  But  even  if  this  be  attempted,  the  loss  of 
blood  would  probably  be  much  greater  than  if  the  whole  bone 
were  removed ;  for  the  wound  is  more  confined,  and  the 
wounded  arteries  are  more  apt  to  retract  behind  the  bone 
above,  and  offer  great  obstacles  to  their  being  secured. 
However,  should  the  lower  angle  be  alone  the  seat  of  disease, 
the  attempt  to  remove  the  lower  portion  only  is  justifiable.  .  .  . 
As  the  removal  of  the  whole  bone  is  not  a  more  formidable 
operation  than  the  removal  of  a  portion  of  it,  and  as  the 
patient  has  less  chance  of  a  recurrence  of  his  disease  if  the 
whole  bone  be  taken  away,  it  should  be  in  a  very  exceptional 
case,  and  on  some  very  pecuhar  merits  of  its  own,  that  the 
surgeon  ought  to  undertake  the  removal  of  a  portion  of  the 
scapula." 

The  instances,  however,  are  not  few  in  which  the  glenoid 
cavity  may  be  saved. 

After-treatment. — A  drain  should  be  introduced  into  the 
lower  part  of  the  wound  for  the  first  24  or  48  hours.  The 
patient  must  occupy  the  recumbent  position,  with  the 
shoulder  and  upper  limb  secured  upon  a  pillow.  As  soon  as 
healing  is  sound,  the  limb  may  be  supported  in  a  sling. 

Results. — The  utility  of  the  limb  preserved  is  often 
remarkable.  Patients  have  recovered  Avith  considerable 
power  in  the  extremity,  have  been  able  to  lift  weights  and 
follow  a  hght  occupation. 

In  Mr.  Symoud's  case  {Clin.  Soc.  Trans.,  vol.  xx.,  page  24) 


66i  OPEEATIVE    SURGERY. 

the  patient  was  able  to  do  all  the  lighter  work  of  a  carpenter, 
incladiug  the  use  of  a  plane.  Overhead  work  he  could  not 
manage. 

Ashhurst  has  collected  42  examples  of  removal  of  the 
entire  scapula.  In  2  the  result  is  unknown ;  32  recovered, 
and  8  died — a  mortality  of  20  per  cent 


665 


CHAPTER    XVI. 

Excisions  of  the  Toes,  Metatarsus,  and  Tarsus. 

The  general  as  well  as  the  detailed  observations  that 
apply  to  the  fingers  and  metacarpus,  apply  also  to  the  corre- 
sponding parts  of  the  foot. 

These  operations  are  but  very  rarely  indeed  carried  out, 
and  not  a  few  of  the  procedures  described  in  the  more  formal 
text-books     have 
no  real  existence 
in  practice. 

A  great  pro- 
portion of  the 
cases  for  which 
excision  has  been 
advised  are  more 
properly  treated 
by  amputation,  or 
by  some  other 
measure. 

The  importance  of  the  great  toe  in  the  general  mechanism 
of  the  foot  is  fully  recognised,  and  the  principal  excision 
operations  that  would  be  considered  under  the  present  head- 
ing have  reference  to  that  digit. 

The  metatarso-phalangeal  joint  of  the  gi'eat  toe  has  been 
excised  for  suppuration  of  the  articulation,  following  abscess 
of  a  bunion.  The  same  joint  has  also  been  excised  for  the 
relief  of  hallux  valgus  (see  osteotomy  for  this  deformity),  and 
the  inter-phalangeal  joint  of  the  second  toe  has  been  excised 
to  remedy  the  mal-position  of  hammer-toe. 

The  removal  of  individual  metatarsal  bones  for  disease 
cannot  be  said  to  have  been  attended  with  satisfactory  results. 

The  metatarsal  bones  and  phalanges  agree  respectively  with 
the  corresponding  bones  of  the  hand  in  the  mode  and  time  of 
their  ossification. 


Fig.  198. — EXCISION  OF  FIRST  ITETATAESAL  BONE. 


666 


OPERATIVE    SURGERY. 


The  operations  upon  the  various  bones  and  joints  are 
can'ied  out  in  the  foot  upon  similar  hnes  to  those  ah'eady 
described  in  connection  with  the  hand. 

The  two  principal  methods  of  excising  the  metatarsal 
bone  of  the  great  toe  are  shown  in  Figs.  198  and  199. 

EXCISION   OF    CERTAIN   BONES    OF   THE   TARSUS. 

MickuHcz's  osteo-plastic  resection  of  the  foot  is  described 
in  the  chapter  on  amputations  (page  456). 

Cuneiform  osteotomy  of  the  foot  is  dealt  with  in  tl:e  chapter 
on  osteotomy  (page  580). 

Excision    of    certain    individual    bones   of  the   tarsus   is 

occasionally  prac- 
tised. The  oper- 
ations concern 
mainly  the  astra- 
galus and  the  os 
calcis. 

The       cuboid 

has  been  removed 

in  the   treatment 

of    severe    forms 

of    talipes.      {See 

Osteotomy  of  the 

Foot,  page  580.) 

Other  of  the  tarsal  bones  have  been  removed — or,  more 

accurately  speaking,  gouged  out — through  a  simple  incision,  in 

cases  of  limited  disease. 

The  Synovial  Membranes  of  the  Foot. — In  dealing  Avith 
individual  bones  of  the  tarsus,  the  position  and  extent  of  the 
synovial  membranes  of  the  tarsal  joints  must  be  borne  in 
mind. 

The  following  are  the  synovial  cavities  of  the  ankle  and 
tarsal  joints  (Fig.  200): — 1.  The  synovial  membrane  of  the 
ankle-joint.  2.  A  sac  between  the  posterior  parts  of  the 
OS  calcis  and  astragalus,  behind  the  interosseous  ligament. 
(Not  shown  in  Fig.  200.)  3.  A  sac  of  synovial  membrane 
which  is  interposed  between  the  anterior  parts  of  the  os  calcis 
and  astragalus,  in  front  of  tlie  interosseous  membrane,  and 
between  the  head  of  the  astragahis  and  the  scaphoid.     4.  A 


Fi 


199. — EXCISION   OF   FIEST  METATAESAL  BONE  : 
METHOD. 


EXCISION  OF   TARSAL  BONES. 


667 


synovial  membrane   between   the   os  calcis   and   the   cuboid. 

5.  One  between    the   external    cuneiform    and   the    cuboid. 

6.  One  between  the  cuboid  and  the  fourth  and  fifth  meta- 
tarsal bones.  7.  A  sac  which  separates  the  mternal  cunei- 
form   from   the    first    metatarsal 

bone.  8.  A  large  and  most  ir- 
regular synovial  membrane  Avhich 
is  insinuated  between  the  re- 
mainmg  bones  of  the  foot,  and 
serves  to  connect  many  articula- 
tions. 

1.  The  Astragalus. 

This  bone  has  been  excised  for 
disease,  esjiecially  for  caries  fol- 
lowing injury  in  healthy  subjects, 
for  gimshot  injuries  of  limited 
extent,  for  irreducible  or  unreduced 
dislocations  of  the  bone,  and  for 
the  rehef  of  some  forms  of  intract- 
able tahpes. 

Anatomical  Points.  —  The 
bone  is  iu  relation  with  the 
synovial  membrane  of  the  ankle, 
with  that  separating  the  os  calcis 
from  the  astragalus  behind  the 
interosseous  lit^ament,  and  with 
that  interposed  between  these  two 
bones  in  front  of  the  ligament, 
and  between  the  posterior  part  of  the  scaphoid  and  the  astragalus. 

The  head  of  the  astragalus  hes  in  a  socket  formed  by  the 
scaphoid,  the  anterior  concave  facet  on  the  sustentaculum 
tali,  and  the  inferior  caleaneo-scaphoid  hgament.  This  power- 
ful ligament  is  covered  with  fibro-cartilage  upon  its  upper 
surface. 

The  ni^st  important  hgament  actuall}^  attached  to  the 
astragalus  is  the  interosseous,  which  passes  between  it  and  the 
os  calcis. 

No  muscles  are  connected  with  this  bone. 

The  astragalus  begins  to  ossif^^  about  the  seventh  month  of 
fcetal  life.     By  the  third  year  the  bone  will  be  about  half  bone 


Fig.  200.- 


-THE    AETICULATIONS 
THE   FOOT. 


668 


OPERATIVE   SUBGEBY. 


and  half  cartilage.     The  osseous  tissue  occupies  the  centre,  the 
cartilaginous  tissue  the  surface  or  periphery. 

The  dorsalis  pedis  artery  crosses  in  front  of  the  bone. 
The  bone  is  most  conveniently  reached  on  the  inner  side 
between  the  tendons  of  the  tibialis  anticus  and  the  tibialis 
posticus,  and  on  the  outer  side  between  the  tendons  of  the 
peroneus  tertius  and  peroneus  brevis. 

Advantage  is  taken  of  these  two  spaces  in  the  operation 
which  follows  : — 

Operation. — The  patient  hes  upon  the  back,  and  the  foot 
is  so  placed  as  to  extend  beyond  the  end  of  the  table.  It 
must  be  held  by  an  assistant,  who  can  manipulate  it  as 
directed. 

Two  incisions,  external  and  internal,  are  made.  The  outer 
incision  is  about  two  and  a  half  inches  in  length,  runs  parallel 

with  and  just 
posterior  to  the 
tendon  of  the 
peroneus  ter- 
tius, and  com- 
mences a  line 
or  so  above 
the  level  of  the 
articular  mar- 
gin of  the  tibia 
(Fig.  201,  A). 

A      second 
and  much 

shorter        cut 


0  - 


Fig.  201. --A,  Excision  of  astragalus  (outer  incision) ;  B,  Exci- 
sion of  ankle  (outer  incision)  ;  C,  Excision  of  os  calcis. 


starts  from  the 
centre  of  the  principal  incision,  is  placed  at  right  angles  to  it, 
and  ends  immediately  below  the  tip  of  the  outer  malleolus. 
The  two  slight  flaps  thus  defined  are  timied  aside,  and  the 
bone  exposed  in  the  interval  between  the  peroneus  tertius 
and  peroneus  brevis  tendons. 

The  foot  is  well  extended  and  inverted,  and  the  ligaments 
which  connect  the  bone  with  the  fibula,  tibia,  scaphoid,  and  os 
calcis,  are  divided  so  far  as  they  can  be  reached  from  the  outer 
side.     Retractors  are  used  to  protect  the  tendons,  etc. 

The  inner  incision  is  about  two  inches  in  length,  and,  start- 


EXCISION  OF  TARSAL  BONES.  669 

ing  from  just  below  the  tip  of  the  inner  malleokis,  is  carried 
forwards  and  upwards  just  in  front  of  the  anterior  margin  of 
that  bone.  It  will  be  curved  therefore,  with  the  concavity 
backwards  (Fig.  202,  a). 

The  remaining  ligaments  that  hold  the  astragalus  are  now 
divided  from  the  inner  side. 

The  surgeon  turns  tinally  to  the  outer  wound,  and,  while 
the  foot  is  inverted  and  extended,  grasps  the  astragalus  with 
lion  forceps  in  a  vertical  direction,  and,  as  Farabeuf  expresses 
it,  "  whips  it  out  like  a  molar." 

The  wound  will  need  to  be  drained,  and  the  limb  to  be 
tirmly  secured  upon  a  splint  or  in  plaster  of  Paris,  with  the 
foot  at  right  angles  to  the  leg. 

Excellent  results  have  followed.  A  useful  but  somewhat 
shortened  extremity  is  produced,  and  no  movement  will 
probably  be  restored  to  the  ankle-joint. 

Some  surgeons  carry  out  the  excision  of  the  bone  through 
a  single  external  wound. 

The  method  of  operating  through  a  transverse  dorsal 
incision  with  division — and  subsequent  suture— of  the  anterior 
tendons  has  little  to  recommend  it. 

2.  The  Os  Calcis. 

This  bone  has  been  removed  for  disease,  and  in  some  cases 
of  injury.  The  arrangement  of  the  synovial  membranes  in 
relation  with  the  bone  is  such  that  mischief  commencinar  in 
the  OS  calcis  is  apt  to  be  limited  to  it. 

Anatomical  Points. — Three  synovial  membranes  are  con- 
nected with  the  surfaces  of  this  bone. 

From  the  upper  surface  of  the  os  calcis  arises  the  extensor 
brevis  digitorum,  and  from  the  plantar  surface  the  first  layer 
of  the  plantar  muscles. 

Many  strong  ligaments  are  attached  to  the  calcaneum,  the 
most  noteworthy  being  the  interosseous,  the  inferior  calcaneo- 
-scaphoid,  the  long  and  short  plantar,  and  the  prolongations  of 
the  lateral  ligaments  of  the  ankle-joint. 

The  principal  nucleus  of  the  os  calcis  appears  in  the  sixth 
month  of  foetal  life.  Before  the  age  of  ten  years  the  posterior 
part  of  the  bone  is  wholly  cartilaginous.  A  nucleus  appears 
at  that  date  in  this  cartilaginous  segment,  and  the  epiphysis 
so  formed  is  united  to  the  rest  of  the  bone  about  the  sixteenth 


670  OPERATIVE    SURGERY. 

year.     The  bloodvessels  of  the  bone  enter  mainly  from   the 
inner  side. 

Operation. — Among  the  many  methods  devised  for  the 
excision  of  this  bone,  the  procedure  described  by  Farabeuf 
appears  to  be  upon  the  whole  the  best.  The  incision  he  recom- 
mends is  a  combination  of  the  horse-shoe  incision  employed 
by  Erichsen,  and  the  simpler  skin-cut  made  use  of  by  Oilier. 

The  operation  should  be  performed  as  far  as  is  possible  by 
the  subperiosteal  method. 

The  patient  hes  upon  the  sound  side,  the  leg  is  supported 
upon  a  sand  pillow,  and  the  foot,  turned  well  upon  its  inner 
border,  is  free. 

The  incision,  commencing  at  the  base  of  the  fifth  meta- 
tarsal bone,  is  carried  horizontally  backwards  just  above  the 
margin  of  the  sole,  and,  passing  round  the  hinder  aspect  of  the 
heel,  ends  about  one  inch  and  a  quarter  to  the  inner  side  of 
the  median  hne  (Fig.  201,  c). 

This  cut  is  met  by  a  vertical  incision  two  inches  in  length,, 
which  is  parallel  to  and  a  little  in  front  of  the  tendo  Achilhs. 
The  wound  is  deepened,  and  two  small  flaps  are  formed.  Great 
care  must  be  taken  of  the  peronei  tendons,  to  which  the 
vertical  incision  is  posterior.  The  bone  is  exposed  behind  the 
peronei  tendons,  and  the  periosteum  is  incised  vertically. 
With  a  rugine  the  periosteum  and  the  associated  Kgaments 
are  separated  from  the  bone.  The  outer  surface  is  cleared 
first,  then  the  posterior  surface.  The  attachment  of  the  tendo 
Achilhs  is  severed.  The  foot  being  placed  in  the  position  of 
talipes  varus,  the  posterior  aspect  is  bared  of  periosteum  as 
far  as  it  is  possible  to  reach.  The  anterior  portion  of  the  bone 
is  cleared,  and  the  hgaments  separated  with  the  periosteum. 
The  same  is  done  Avith  the  plantar  surface.  A  certain  part  of 
the  inner  surface  can  be  reached  from  the  posterior  aspect. 

With  care  and  patience  and  the  use  of  good  retractors  the 
greater  part  of  the  bone  can  be  bared  through  this  outer- 
incision,  and  from  this  side  also  the  interosseous  ligament  can 
be  reached  and  divided. 

When  the  os  calcis  is  as  far  freed  as  possible,  the  head  or 
anterior  part  must  be  grasped  with  lion  forceps,  and  the  bone 
drawed  outwards  with  a  repeated  rotatory  movement,  the 
periosteum    and    ligaments    njton    the   inner   surface   being^ 


EXCISION  OF  TARSAL  BONES.  671 

separated  with  the  ruginc  as  soon  as  each  part  of  the  as-yet- 
untouched  district  is  reached. 

Comment. — This  operation  can  be  performed  upon  the 
cadaver  in  the  systematic  manner  just  described,  but  in 
practice  so  formal  a  procedure  can  seldom  be  carried  out. 

Sinuses  may  have  to  be  considered,  and  carious  and 
broken-down  bone  to  be  dealt  with.  A  not  inconsiderable 
part  of  the  bone,  in  cases  of  disease,  may  be  removed  with  the 
gouge  or  sharp  spoon,  and  such  parts  of  the  compact  tissue 
as  are  healthy  may  be  left  as  a  kind  of  thin  osseous  mould. 

The  operations  which  are  characterised  by  the  formation 
of  a  U-shaped  plantar  flap  are  to  be  condemned,  on  account 
of  the  unnecessary  damage  they  inflict  upon  the  tissues  of  the 
sole. 

In  an  operation  carried  out  by  Mr.  Holmes  ("  System  of 
Surgery,"  vol.  iii.,  page  771)  the  peronei  tendons  are  divided,  a 
step  which  has  little  to  recommend  it. 

The  foot  must  be  fixed  at  a  right  angle  with  the  leg,  and 
the  heel  allowed  to  be  free. 

An  anterior  well-moulded  metal  splint  answers  the  pur- 
pose well.  After  the  splint  has  been  appHed,  the  limb  must 
be  suspended  in  a  suitable  apparatus. 

This  protects  the  foot  from  any  pressure,  and  allows 
efficient  drainage  to  be  carried  out. 

The  results  obtained  from  this  operation  have  been  most 
satisfactory.  According  to  Vincent's  statistics,  647  per  cent, 
of  those  operated  on  have  recovered  with  useful  limb,  while 
only  5  per  cent,  have  died. 


«72 


CHAPTER    XVII. 

Excision  of  the  Ankle. 

This  excision  is  of  but  limited  application,  and  is  compara- 
tively rarely  performed.  In  the  first  place,  the  modern 
improvements  in  the  methods  of  treating  wounds  are  such 
that  a  large  proportion  of  the  cases  of  disease  of  the  joint  yield 
to  simple  surgical  measures.  Those  who  advocate  the  excision 
of  the  joint  for  disease  urge  that  it  should  be  performed  early ; 
but  probably  the  majority  of  surgeons  would  prefer  to  defer 
any  radical  measure  until  treatment  by  rest,  drainage,  and 
favourable  hygienic  conditions  had  been  tried. 

In  the  second  place,  amputation  of  the  foot  leads  to  ver}^ 
admirable  results,  and  the  excision  of  the  ankle  must  have  a 
very  happy  termination  if  it  can  yield  a  more  useful  ex- 
tremity than  that  left  after  a  successful  Syme's  amputation. 

In  not  a  few  cases  the  disease  has  extended  so  far  beyond 
the  actual  area  of  the  ankle-joint  that  the  operation  of 
excision  could  not  be  entertained. 

The  after-treatment  of  these  excision  cases  is  difficult  and 
anxious,  and  demands  infinite  and  long-continued  care.  This 
circumstance  in  itself  afibrds  a  substantial  objection  to  the 
operation. 

The  ankle  has  been  excised  in  many  cases  of  injury, 
notably  in  compound  dislocation  and  in  instances  of  complex 
fi-acture.  Here,  also,  the  position  of  this  class  of  case  has 
been  very  materially  altered  by  the  modern  methods  of  Avound 
treatment,  and  many  a  foot  which  twenty  years  ago  would 
have  been  amputated  or  treated  by  excision  is  now  saved. 

The  excision  of  the  ankle  to  remedy  deformity  resulting 
from  malunited  fracture — e.g.,  severe  Potts's  fracture — is  in 
the  present  day  usually  replaced  by  a  linear  or  cuneiform 
osteotomy. 

During  the  last  five  years  no  excision  of  the  ankle  has 


EXCISION   OF  ANKLE.  673 

been  performed  at  the  London  Hospital,  and  examples  of  the 
operation  have  mostly  to  be  sought  for  among  older  records. 

In  dealing  with  excision  of  the  ankle  for  disease  Mr. 
Howard  Marsh  writes :  "  It  is  but  seldom  performed ;  and  when 
it  is  performed,  the  result  is  usually  unsatisfactory." 

The  first  excision  of  the  ankle  was  carried  out  by  Moreau 
in  1792.  The  patient  was  the  subject  of  caries,  and  an  ex^ 
cellent  result  followed. 

The  first  operation  of  this  kind  performed  in  England  was 
undertaken  in  1851  by  Mr.  Hancock. 

For  some  twenty  years  following  this  date  a  considerable 
number  of  excisions  of  the  ankle  were  performed. 

Anatomical  Points. — The  ankle-joint  forms  a  very  power- 
ful articulation,  its  strength  being  derived  not  only  from  the 
shape  of  its  component  bones,  but  also  from  the  unyielding 
ligaments  and  the  many  tendons  which  are  bound  about  it  like 
straps.  Of  the  ligaments,  the  two  lateral  are  very  strong,  and 
have  an  extensive  hold  upon  the  foot.  The  anterior  and 
posterior  are,  on  the  other  hand,  extremely  thin  and  insignifi- 
cant, although  the  latter  is  supported  by  the  tendon  of  the 
flexor  longus  pollicis,  which  crosses  it. 

The  loose  synovial  sac  of  the  ankle-joint  extends,  both  in 
front  and  behind,  beyond  the  limits  of  the  articulation,  while 
at  the  sides  it  is  strictly  limited  to  the  joint  surfaces.  The 
ankle  is  a  perfect  hinge-joint,  and  permits  only  of  flexion  and 
extension. 

The  outlines  of  the  two  malleoli  can  be  distinctly  defined. 
The  external  is  somewhat  the  less  prominent,  descends  lower, 
and  lies  farther  back  than  the  internal  process. 

The  tip  of  the  outer  malleolus  is  about  half  an  inch  be- 
hind and  below  the  tip  of  the  corresponding  bony  jDrominence. 

The  head  of  the  astragalus  can  be  made  out  upon  the 
dorsum  of  the  foot  when  the  limb  is  fuUy  extended. 

About  one  inch  and  a  quarter  in  front  of  the  inner 
malleolus  the  tubercle  of  the  scaphoid  can  be  felt.  Just 
behind  it  is  the  astragalo-scaphoid  joint. 

On  the  outer  side  of  the  foot  the  external  surface  of  the 
OS  calcis  is  subcutaneous  in  nearly  the  whole  of  its  extent. 
Less  than  an  inch  below  and  in  front  of  the  malleolus  is  the 
peroneal  tubercle,  with  the  short  peroneal  tendon  above  it, 


674  OPERATIVE    SURQEBY. 

and  the  long  one  beloAv  it.  The  anlde-joint  Hes  about  on  the 
level  of  a  point  half  an  inch  above  the  tip  of  the  inner 
malleoliis. 

The  position  of  the  tendons  about  the  ankle-joint  must  be 
borne  in  mind,  as  also  the  situation  of  the  tibial  and  peroneal 
arteries. 

The  lower  epiphysis  of  the  tibia  includes  the  articular  sur- 
face and  the  internal  malleolus.  Ossification  commences  in  it 
during  the  second  year,  and  the  epiphysis  joins  the  shaft  be- 
tween the  eighteenth  and  nineteenth  years.  The  lower  epi- 
physis of  the  fibula  includes  the  articular  surface  and  outer 
malleolus.  Ossification  commences  in  the  second  year,  and  is 
completed  about  the  twenty-first  year.  Both  epiphyseal  lines 
are  horizontal,  and  are  brought  in  contact  with  that  pouch 
of  synovial  membrane  which  extends  upwards  between  the 
tibia  and  fibula. 

Operation. — The  various  methods  in  vogue  for  performing 
this  operation  are,  for  the  most  part,  modifications  of  the 
original  procedure  of  Moreau.  Indeed,  no  very  conspicuous 
deviations  from  the  initial  operation  have  been  proposed  or 
carried  out.  Of  the  modern  forms  of  Moreau's  operation,  that 
by  Langenbeck  would  appear  to  be  one  of  the  best.  It  may 
be  carried  out  as  follows,  if  the  subperiosteal  method  be 
attempted : — 

The  patient  lies  upon  the  back,  with  the  foot  and  leg  sup- 
ported upon  a  firm  sand  pillow.  Two  vertical  lateral  incisions 
are  made. 

1.  The  Older  Incision. — The  foot  being  turned  over  upon 
its  inner  side,  a  vertical  incision  some  three  inches  in  length  is 
made  along  the  anterior  part  of  the  fibula  to  a  point  a  little 
below  the  tip  of  the  malleolus.  Thence  it  is  made  to  curve 
around  the  malleolus,  and  ascend  for  about  one  inch  along  its 
posterior  border  (Fig.  201,  b). 

2.  The  Removal  of  the  Fibula. — The  fibula  is  exposed, 
and  its  periosteum  divided  in  the  long  axis  of  the  bone.  The 
membrane  is  then  separated  from  the  bone  by  the  rugine  in 
an  anterior  and  a  posterior  direction. 

The  ligaments  attached  to  the  malleolus  are  separated 
as  encountered.  The  external  lateral  ligament  is  divided 
vertically,   so   that   its   anterior    segment   will   go   with   the 


EXCISION  OF  ANKLE. 


»)75 


anterior  layer  of  separated  periosteum,  and  its  hinder  segment 
with  the  posterior  layer. 

With  the  curved  rugine  the  greater  part  of  the  circum- 
ference of  the  shaft  of  the  bone  can  be  bared  about  the 
saw-line. 

The  fibula  is  then  divided  with  either  a  chisel  or  a  saw 
about  one  inch  above  its  extremity.  The  divided  end  is 
seized  with  lion  forceps,  or  is  drawn  outwards  with  a  hook, 
while  its  deeper  connections  are  separated  with  the  rugine, 
aided  by  the  knife. 

This  part  of  the  operation  is  very  tedious. 

The  lower  end  of  the  fibula  is  thus  removed. 

3.  The  Clearing  of  the  Tibia. — As  much  of  the  anterior 
and  posterior  surfaces  of  the  tibia  as  can  be  reached  through 
the  outer  cut  are  bared  of  periosteum  by  means  of  the  rugine, 
the  anterior  and  posterior  hgaments  of  the  ankle  being 
elevated  with 

the  periosteal  / 

layers.         In 

this    part    of 

the  operation, 

care  must  be 

taken  not  to 

open  the 

sheaths  of  the 

tendons. 

4.  The  In- 
ner Incision. 
— The  foot  is 
turned  upon 
its  outer  side, 
and  an  inci- 
sion about  three  inches  long  is  made  along  the  inner  surface 
of  the  tibia,  and  in  the  long  axis  of  the  bone.  The  cut  ends 
at  the  tip  of  the  inner  malleolus.  A  curved  or  transverse 
incision  (Fig.  202,  b)  may  be  made  to  meet  the  lower  end 
of  this  wound  at  right  angles. 

5.  The  Removal  of  the  Tibia. — The  periosteum  of  the 
tibia  is  incised  vertically,  and  that  membrane  is  peeled  from 
the  bone  so  that  it  may  be  continuous  with  the  periosteo- 

K  R  2 


Fig.  202. — A,  Excision  of  astragalus  (inner  incision) ;  B,  Exci- 
sion of  ankle  (inner  incision). 


676  OPERATIVE    SUIiGEBY. 

capsular  layers  already  separated  upon  the  outer  side.  The 
mternal  lateral  ligament  is  divided  verticall}'^  in  the  manner 
already  described  with  regard  to  the  outer  ligament. 

As  soon  as  the  tibia  is  sutticiently  free,  the  malleolar  end  of 
it  is  made  to  project  a  little  through  the  wound,  and  while 
the  soft  parts  are  well  protected  with  retractors,  the  bone  is 
divided  horizontally  with  a  key-hole  saw.  The  fragment  is 
grasped  with  lion  forceps  and  removed. 

6.  The  Sawing  of  the  Astragalus. — The  surgeon  hnally 
turns  once  more  to  the  outer  incision,  and  through  that 
w^ound  removes  with  the  saw  as  much  of  the  upper  part  of 
the  astragalus  as  is  necessarj^  The  section  should  be  hori- 
zontal. If  thought  necessary,  the  whole  of  the  astragalus 
miay  be  removed  through  the  external  incision. 

Comment. — The  operation  just  described  follows  the 
subperiosteal  method,  and  in  all  suitable  cases  that  form  of 
excision  should  be  observed  so  far  as  is  possible. 

The  ankle  is  peculiarly  well  adapted  for  the  employ- 
ment of  the  subperiosteal  method,  and  the  excellence  of  the 
results  obtained  in  some  reported  cases  has  been  ascribed 
to  the  sparing  of  the  periosteum  and  the  ligaments.  Sir 
Wm.  MacCormac  observes  that  "  no  form  of  subperiosteal 
excision  can  be  performed  more  thoroughly  than  that  at 
the  ankle." 

The  lateral  incisions  may  vary  considerably  fi'om  those 
described  in  the  text. 

The  outer  incision  ma}^  follow  the  posterior  border  of  the 
fibula,  and  be  made  to  bend  suddenly  forwards  beneath  the 
malleolus,  when  the  tip  of  that  process  is  reached.  This  was 
the  outer  incision  of  Moreau.  Or  a  vertical  cut  so  placed 
may  be  met  by  a  transverse  line,  which  extends  as  far 
forwards  as  the  tendon  of  the  peroneus  tertius. 

The  inner  incision  has  been  made  to  form  a  U-shaped  flap 
corresponding  in  Avidtli  to  the  shaft  of  the  tibia,  or  has  assumed 
something  of  the  outline  of  an  anchor,  a  vertical  cut  being 
joined  by  a  transverse  incision  at  its  upper  end  and  a  curved 
one  at  its  lower. 

The  operation  by  means  of  a  transverse  incision  across 
the  front  of  the  ankle-joint  may  be  absolutely  condemned.  It 
is  not  adapted  for  the  subperiosteal  method,  many  tendons 


EXCISION  OF  ANKLE.  677 

■must  be  cut,  synovial  sheaths  are  opened  up,  anrl  tlie  anterior 
tibial  artery  may  need  to  be  secured. 

The  removal  of  the  entire  astragalus  is  insisted  upon  by 
many  who  advocate  the  operation  in  cases  of  bone  disease. 

Farabeuf  saws  through  the  tibia  and  fibula  together,  using 
a  key-hole  saw,  and  protecting  the  soft  parts  with  retractors. 

Some  operators  take  no  trouble  to  save  the  peronei 
tendons  from  division. 

Most  essential  is  it  that  every  care  should  be  taken  of  the 
sheaths  of  the  tendons. 

Some  surgeons,  after  the  removal  of  the  fibula,  saw  off  the 
upper  part  of  the  astragalus,  then  make  the  inner  incision, 
and  finally  remove  the  tibial  segment. 

After-treatment. — The  after-treatment  is  a  matter  of 
extreme  importance,  and  may  have  a  greater  influence  upon 
the  success  of  the  measure  than  the  actual  operation  itself. 
The  foot  and  leg  must  be  fixed  in  a  suitable  splint,  the  line 
of  the  new  joint  being  rectangular.  A  plaster-of- Paris  dress- 
ing, with  windows  to  permit  of  drainage  and  the  inspection 
of  the  wound,  is  recommended  by  many ;  or  in  the  place  of 
it  a  special  splint  of  light  wire  may  be  employed.  It  is 
desirable  that  the  limb,  when  fixed  in  the  apparatus  selected, 
should  be  suspended  from  a  suitable  cradle.  The  gap  left 
by  the  removal  of  the  bones  shoidd  be  maintained  by 
extension. 

Great  care  must  be  taken  to  keep  the  foot  in  a  straight  line 
with  the  leg,  as  a  lateral  deviation  of  the  limb  is  very  easily 
produced  if  this  point  be  not  strictly  attended  to.  "  If 
motion  be  sought  for,  passive  movements  ought  to  be  com- 
menced very  early  ;  but  sound  anchylosis  is  the  most  common 
and  most  desirable  result. 

"It  is  afterwards  necessary  to  -wear  an  instrument  with 
lateral  cross  supports  for  a  considerable  time,  in  order  to 
'prevent  any  givmg  way  of  the  new  joint.  A  support  behind, 
in  the  form  of  an  artificial  gastrocnemius,  is  often  useful ;  this 
is  effected  by  means  of  a  rubber  cord  attached  to  the  heel 
of  the  shoe  and  to  a  strap  at  the  knee.  The  os  calcis 
is  prevented  from  slipping  forwards  by  this  means " 
(^MacCormac). 

Results. — The   older   statistics   (as  represented   by  those 


678  OPERATIVE    SURGERY. 

collected  by  Culbertson)  give  a  mortality  of  8  5  per  cent,  in 
cases  of  disease,  12-5  per  cent,  in  cases  of  injury,  and  26'7 
per  cent,  in  cases  of  gunshot  wound. 

This  mortahty  has  been  substantially  reduced  by  improved 
methods  of  treating  the  wound,  and  in  any  case  is  considerably 
beloAv  that  which  follows  amputation  through  the  lower  part 
of  the  leg. 

Firm  anchylosis  is  the  usual  result  obtained  ;  and  when 
this  has  followed,  most  useful  limbs  have  resulted. 

The  condition  of  flail-joint  is  unknown. 

Langenbeck  states  that  in  75  per  cent,  of  the  cases  with 
which  he  has  himself  dealt,  the  patients  recovered  with  a 
useftd  limb. 

The  shortening  that  results  is  usually  slight,  not  more 
than  one  inch,  and  is  compensated  for  by  a  thick  sole  to  the 
boot  worn. 

Farabeuf  recommends  that  if  much  shortening  be  antici- 
pated, the  bones  should  be  so  sawn,  and  the  limb  so  adjusted 
after  the  operation,  that  a  slight  degree  of  talipes  equinus  is 
brought  about. 

In  many  instances  the  patient  has  recovered  with  a  new 
joint,  in  which  a  remarkable  degree  of  movement  was  present. 

If  the  subperiosteal  method  can  be  carried  out,  the  re- 
production of  new  bone  is  often  singularly  complete.  It  may 
be  excessive,  but  even  when  imperfect,  the  amount  of  new 
tissue  produced  is  sufficient  to  assist  considerabty  in  the 
estabhshment  of  a  useful  limb. 

Wlien  anchylosis  follows,  much  compensatory  movement 
is  generally  developed  in  the  medio-tarsal  joint. 

EXCISION   OF   THE   TIBIA   AND    FIBULA. 

The  whole  or  some  part  of  the  diaphysis  of  the  tibia 
has  been  removed  in  cases  of  diffused  suppurative  periostitis, 
especially  in  young  subjects. 

If  the  periosteum  be  fairly  whole,  and  the  subperiosteal 
method  be  strictly  carried  out,  the  reproduction  of  noAv  bone 
is  usually  sufficient  to  leave  the  patient  with  a  useful  limb. 

The  ends  of  the  tibia  and  fibula  were  sawn  off  in  a  case  of 
compound  dislocation  of  the  ankle  some  years  before  the 
operation  of  excision  of  the  ankle  Avas  carried  out. 


EXCISION  OF  ANKLE.  67? 

The  incisiou,  in  doaling  with  the  tibia,  should  be  vertical, 
and  be  parallel  to,  and  just  in  front  of,  the  internal  border  of 
the  bone.  When  the  part  to  be  removed  has  been  bared,  the 
bone  may  be  severed  with  a  chain-saw  or  a  chisel. 

In  cases  in  which  the  tibia  is  sound,  removal  of  very 
considerable  portions  of  the  fibula  may  be  undertaken  without 
any  marked  deformity  of  the  limb  resulting.  It  is  well  that 
the  upper  and  lower  ends  should  be  preserved  whenever 
possible. 

In  removing  the  head  of  the  fibula,  it  is  possible  to  effect 
an  opening  into  the  knee-joint,  or  to  do  damage  to  the  anterior 
tibial  and  musculo-cutaneous  nerves. 

If  the  malleolus  be  excised,  the  foot  is  apt  to  become 
everted. 

In  deahng  with  the  upper  half  of  the  fibula  the  incision 
should  be  carried  along  the  posterior  part  of  the  bone  so  as 
to  fall  behind  the  peroneal  muscles. 

In  dealing  with  the  lower  half  it  may  follow  a  continuation 
of  the  long  axis  of  the  outer  malleolus,  and  be  placed  there- 
fore in  front  of  the  muscles. 


680 


CHAPTEK    XVIII. 

EXCISIOX     OF     THE      KXEE. 

This  extensive  and  serious  operation  has  been  performed 
for  numerous  conditions,  but  is  now  mainly  limited  to  the 
treatment  of  certain  forms  of  chronic  joint  disease. 

In  acute  disease  it  has  been  comparatively  unsuccessful, 
and  in  the  present  position  of  surgery  may  be  regarded  as 
almost  unjustifiable. 

It  is  but  very  rarely  demanded  in  examples  of  complicated 
and  compound  fracture  and  dislocation. 

The  results  that  have  attended  the  operation  when 
performed  for  gunshot  injuries  have  been  such  that  the 
measure  is  considered  by  most  surgeons  to  be  contra-indicated 
in  these  cases. 

As  a  means  of  treating  anchylosis  in  a  deformed  position, 
excision  has  been  almost  entirely  replaced  by  osteotomy. 

The  value  of  the  operation  has  been  the  subject  of  long- 
continued,  elaborate,  and  voluminous  discussion,  and  the 
position  of  the  procedure  has  been  substantially  modified  by 
improved  methods  of  treating  joint  affections,  by  improved 
means  of  dealing  with  wounds,  and  by  the  introduction  of  the 
operation  known  as  arthrectomy. 

Excision  of  the  knee  was  first  deliberately  performed  by 
Park  in  1781.  The  patient  was  the  subject  of  chronic  dis- 
ease of  the  joint,  and  an  excellent  result  followed.  A  less 
definite  operation  had  been  previously  carried  out  by  Felkin, 
of  Norwich,  in  1762. 

For  many  years  subsequent  to  that  date  excision  of  the 
knee  was  but  very  rarely  performed,  and  the  operation  Avas 
regarded  most  unfavourably.  The  measure  was,  however, 
revived  by  Fergusson  in  1850,  and  during  the  twenty  or 
thirty  years  after  this  time  the  operation  was  taken  up 
by  EngHsh,  French,  German,  and  American  surgeons,  with 


EXCISION  OF  KNEE.  681 

a  remarkable  enthusiasm,  and  the  recorded  cases  pubHshed 
during  the  period  named  may  be  counted  by  hundreds.  Of 
late  years  a  reaction  has  taken  place,  and  excision  of  the  knee 
has  now  a  place  among  operations  which  are  but  rarely  per- 
formed, or  which  are  extensively  practised  but  by  very  few. 

At  the  present  time  excision  of  the  knee  is  but  rarely 
carried  out  in  private  practice,  and  in  hospital  wards  the  pro- 
cedure would  appear  to  be  becoming  rarer  and  rarer. 

The  result  aimed  at  is  the  production  of  a  rigid  anchylosis 
in  the  extended  position,  and  the  attempts  to  obtain  a  mobile 
joint  have  met  with  very  few  successes  and  a  very  numerous 
list  of  lamentable  failures. 

The  subperiosteal  method  can  hardly  be  carried  out  in 
this  articulation,  and  may  be  considered  as  inapj)licable. 

The  after-treatment  is,  on  the  whole,  of  more  importance 
than  the  operation  itself  Displacement  of  the  bones — and 
notably  a  gliding  of  the  femur  forwards — is  very  apt  to  occur. 

In  young  subjects  great  care  must  be  taken  not  to  en- 
croach upon  the  lower  epiphysis  of  the  femur,  which  is  the 
most  important  epiphysis  of  the  lower  extremity. 

An  admirable  criticism  of  the  operation  is  provided  by 
Mr.  Howard  Marsh  in  his  manual  on  "  Diseases  of  the  Joints." 

Anatomical  Points.— This  articulation  is  the  largest  in 
the  body,  and  owes  its  great  strength  to  the  powerful  ligaments 
which  unite  the  two  component  bones,  and  to  the  muscles 
and  fasciae  that  surround  it.  It  derives  no  strength  from 
the  shape  of  the  articular  surfaces,  since  they  are  mere!}- 
placed  in  contact  with  one  another. 

The  axis  of  the  limb  is  abruptly  altered  at  the  knee-joint, 
the  femur  inclining  inwards  from  the  pelvis,  and  the  tibia 
being  vertical. 

The  lateral  ligaments  of  the  joint  are  comparatively  feeble, 
the  posterior  ligament  is  substantial,  and  the  anterior  part  of 
the  capsule  is  formed  of  a  firm  aponeurotic  expansion.  The 
most  powerful  and  most  important  ligaments  of  the  joint  are 
the  crucial. 

The  synovial  membrane  of  the  knee-joint  extends  upwards 
as  a  large  cul-de-sac  above  the  patella  and  beneath  the 
extensor  tendon  (Fig.  203).  This  cul-de-sac  reaches  a  point  an 
inch  or  more  above  the  upper  margin  of  the  trochlear  surface 


682 


OPERATIVE    SURGERY. 


of  the  femur,  and  is  rendered  very  distinct  when  the  joint  is 

distended  with  fluid  (Fig.  203). 

Above  the  synovial  pouoh  is  a  bursa   which  separates  the 

quadriceps  tendon  from 
the  femur  and  is  usually 
over  an  inch  in  its  verti- 
cal measurement. 

This  bursa  communi- 
cates with  the  synovial 
cavity  in  about  eight 
cases  out  of  ten. 

The  upper  third  of 
the  patellar  ligament  is 
in  relation  with  the 
synovial  membrane,  from 
which,  however,  it  is 
separated  by  a  pad  of 
fat ;  the  lower  two-thirds 
of  the  Hgament  are  in 
relation  with  the  bursa 
between  the  ligament  and 
the  tubercle  of  the  tibia. 
A  knife  jDassed  hori- 
zontally backwards  at 
the  apex  of  the  patella 
would,  when  the  healthy 
limb  is  extended,  just 
miss  the  joint-line  be- 
tween   the    femur    and 

tibia,  and  would  hit  the  latter  bone.     If,  however,  there  be 

any  effusion  in  the  joint,  or  the  limb  be  a  little  flexed,  a  knife 

so  introduced  would  pass  between  the  two  bones  (Fig.  203). 
The  irregularity  of  the  synovial  cavity  lends  itself  to  the 

collection  of  masses  of  diseased  tissue  within  the  joint. 

In  the  popliteal  space  the  large  bursa  which  is  interposed 

between  the  internal  condyle  of  the  femur,  the  inner  head  of 

the  gastrocnemius,  and  the  semi-membranosus,  usually  com- 

Tiiimicates  with  the  knee-joint. 

The  bursa  Ijcneath  the   popliteus   tendon   usually   opens 

into    the   superior    tibio-flbul.ir  joint   on  the  one  hand,  and 


Fig.      203. — TEETICAI,     SECTION      OF     KNEE-JOINT 
DISTENDED  "WITH  FLTHD.       {Braillie.) 

«,  Vastus  exteraus ;  h,  Crureus ;  c,  Short  head, 
and  d,  Long  head  of  biceps  ;  e,  Plantaris  ;  /, 
(iastrocnemius;  g,  Popliteus;  h,  Soleus ;  i, 
Tibialis  posticus  ;  j.  Bursa  patellae ;  k,  Liga- 
nientum  i^atellte  ;  I,  Ligamentum  mucosum  ;  m, 
Anterior  crucial  ligament ;  n.  External  semi- 
lunar cartilage  ;  1,  External  popliteal  nerve  ; 
2.  Popliteal  artery. 


EXCISION  OF  KXEE. 


683 


always  leads  into  the  knee-joint  on  the  other.  It  serves 
therefore  to  establish  a  comuiiniication  between  these  two 
articulations. 

The  upper  limit  of  the  femoral  epiphysis  will  be  represented 
by  a  horizontal  line  drawn  across  the  bone  at  the  level  of  the 
tubercle  for  the  adductor  magnus. 
If  the  Avhole  of  the  trochlear  sur- 
face be  removed  in  the  excision, 
the  whole  of  the  epiphysis  will 
have  been  taken  away  (Fig.  204). 
A  single  nucleus  appears  in  this 
epi[)hysis  shortly  before  birth, 
and  joins  the  shaft  about  the 
twentieth  year.  The  epiphyseal 
line  is  intracapsular. 

The  hmits  of  the  tibial  epi- 
physis are  represented  beliind 
and  at  the  sides  by  a  horizontal 
line  that  just  marks  off  the 
tuberosities.  It  includes,  there- 
fore, the  depression  for  the  inser- 
tion of  the  semi-membranosus, 
and  also  the  facet  for  the  fibula. 

In  front  the  epiphyseal  hne 
slopes  doA\Tiwards  on  either  side 
to  a  point  on  the  upper  end  of 
the  shin,  so  as  to  enclose  the 
whole  of  the  tubercle  of  the  tibia. 

The  centre  joins  the  main 
bone  at  the  twenty-first  or 
twenty-second  year.  The  epi- 
physeal hne  is  extra-articular. 
Farabeuf  estimates  that  in  a  child  of  about  eight  years  of  age 
it  is  unpossible  to  remove  more  than  1  cm,  of  the  tibia,  or  It 
cm.  (xV  of  an  inch)  of  the  femur,  without  approaching  danger- 
ously to  the  epiphyseal  hnes. 

After  puberty  (e.g.,  in  a  youth  of  seventeen  years)  it  is 
possible  to  remove  1|  cm.  of  the  tibia,  and  2|  cm.  (1  inch)  of 
the  femur,  without  compromising  the  epiphyseal  lines. 

The  popliteal  artery  is  so  placed  that  it  is  in  greater  risk 


204.  —EPIPHYSES  OF  THE  FEMUE, 
TIBIA,    AND   FIBULA- 


684 


OPERATIVE    SURGERY. 


of  being  wounded  when  the  tibia  is  sa^vn  than  when  the  lower 
part  of  the  femur  is  being  removed. 

1.  Operation  by  a  Curved  Transverse  Anterior  Incision. 
Of    the   many   methods   that   have    been   described  and 
adopted,  this  appears  to  have  substantial  claims  to  be  regarded 
as  the  most  suitable. 

The  particular  incision  employed  is  accredited  to  Textor, 
and  a  very  similar  incision  was  used  by  Sanson  and  Begin. 

Position. — The  patient  lies  upon  the  back,  with  the  limb 

close  to  the  margin  of  the  table.     The  lower  part  of  the  leg 

should  project  a  little  beyond  the  table,  so  that  when  the 

knee  is  bent  at  a  right  angle  the  foot 

may  be  able   to   rest,   flat   upon   the 

sole,  upon  the  end  of  the  table. 

The  surgeon  stands  upon  the  side 
to  be  operated  on. 

Some  surgeons  prefer  to  stand 
upon  the  left  side  of  the  limb  in  the 
case  of  either  extremity,  a  position 
which  is  certainly  more  convenient 
for  sawing. 

One  assistant  places  himself  oppo- 
site to  the  surgeon,  and  steadies  the 
Hmb  by  the  thigh.  Another  assistant 
near  the  foot  of  the  table  holds  the 
leg,  and  manipulates  it  as  required. 
A  third  assistant  by  the  surgeon's 
side  attends  to  the  sponging,  etc. 

At  the  commencement  of  the 
operation  the  limb  is  held  with  the 
knee  a  little  flexed.  Latei",  the  joint 
is  bent  at  a  right  angle. 

1.  The  Skin  Incision. — A  curved 
incision,  convex  downwards,  is  made  across  the  front  of  the 
knee  beloAv  the  patella. 

The  incision  commences  and  terminates  at  the  posterior 
margin  of  one  of  the  femoral  condyles,  while  its  lowest  point 
in  front  corresponds  with  the  insertion  of  the  patellar  ligament 
(Fig.  205,  A). 

During  the  making  of  this  wound  the  knee-joint  is  held 


Fig 


205.— EXCISION    OF    THE 
KNEE. 


A,  Transverse  curved  incision 
B,  Park's  incision. 


EXCISION  OF  KNEE. 


685 


a  little   flexed,  and  the  skin    and  subcutaneous  tissues  are 
alone  divided  at  the  first  sweep  of  the  knife. 

2.  The  Dividing   of  the   Ligaments. — The   knee   is   now 
flexed  a   little  more,  and  with  another  sweep  of  the  knife 


Tig.    206. — EXCISION    OF    THE     KNEE  :     THE    SAWING    OF    THE     LOWEE     END    OF    THE 

FEMUE.     {After  Farahciif.) 
The  soft  parts  are  retracted  bj'  a  band  of  india-rubber  or  a  loop  of  thin  metal. 


the  anterior  part  of  the  capsule  and  the  patellar  ligament  are 
cut  through,  and  the  joint  opened  below  the  knee-cap. 

The  patella,  with  its  attached  aponeurosis,  is  turned  up- 
wards, the  joint  is  still  more  flexed,  and  the  surgeon  proceeds 
to  divide  in  order  the  lateral  and  the  two  crucial  ligaments. 

3.  The  Sawing  of  the  Femur. — The  joint  is  noAv  bent  at 
A  right  angle,  and  the  hmb  held  flrmly  in  that  position,  with 
the  sole  of  the  foot  planted  upon  the  table. 
.     The  femur  is  cleared  with  the  knife  at  the  future  saw-line. 

The  bone  is  sawn  fi-om  before  backwards,  and  with  resrard 
to  the  plane  of  the  section  these  two  points  must  be  observed : 

The  plane  of  the  saw-cut  in  the  antero-posterior  direction 
must  be  at  right  angles  to  the  long  axis  of  the  shaft  of  the 
femur,  and  in  the  transverse  direction  it  must  be  parallel  to 
the  plane  of  the  free  surface  of  the  condj'les. 


686  OPERATIVE    SURGERY. 

During  the  sawing  process  the  condyles  may  be  grasped 
and  steadied  with  Hon  forceps,  although,  if  the  hmb  be  firmly 
held,  this  is  not  necessary.  The  femur  rests  upon  the  tibia. 
The  tissues  of  the  ham  must  be  protected  by  means  of  an 
ivory  spatula  held  behind  the  femoral  condyles,  or  by  a  broad 
elastic  or  thin  metal  band,  as  shown  in  Fig.  206. 

4.  The  Sawing  of  the  Tibm. — The  upper  end  of  the  tibia, 
is  now  held  forwards,  the  foot  is  still  pressed  firmly  against  th-e 
table,  the  shaft  of  the  bone  is  maintained  in  the  vertical 
position,  and  in  consequence  the  articular  surface  will  be 
quite  horizontal.  The  bone  is  cleared  with  the  knife  for  the 
passage  of  the  saw,  and  a  thin  slice  is  removed  by  sawing 
from  before  backwards,  the  saw  being  kept  precisely  parallel  to 
the  articular  surface,  and  therefore  at  right  angles  to  the 
shaft  (Fig.  207).  The  popliteal  tissues  must  be  protected  in  the 
manner  already  described ;  and  if  the  movements  of  the  saw 
be  slow  and  deliberate,  there  is  no  danger  of  wounding  the 
structures  of  the  ham. 

The  two  bony  surfaces  should  now  be  parallel,  and  should 
fit  accurately  when  brought  together. 

5.  The  Treatment  of  the  Pattella  and  Synovial  Mem- 
brane.— The  most  tedious  part  of  the  operation  remains. 
The  patella  must  be  dealt  with  according  to  the  practice  of 
the  individual  surgeon.  It  may  be  removed,  whether  healthy 
or  diseased,  by  dissecting  it  out,  with  the  least  possible 
disturbance  of  the  surrounding  tissues ;  or  if  entirely  sound, 
it  may  be  left.  Or  it  may  be  steadied  in  a  vertical  position 
while  its  articular  segment  is  removed  with  the  saw  in  the  form 
of  a  thin  layer ;  or  its  tissue  may  be  so  scraped  and  cut  away 
that  nothing  remains  but  the  anterior  layer  of  compact  bone. 

With  the  knife  and  scissors,  aided  by  the  sharp  spoon,  the 
surgeon  now  proceeds  to  remove  all  the  diseased  s}Tiovial 
membrane  which  may  remain.  The  pouch  beneath  the 
quadriceps  tendon  is  opened  up,  and  is  carefully  cleared  oiLt 
by  means  of  the  sharp  spoon. 

Any  existing  sinuses  are  opened  up  and  scraped,  and  by 
one  means  or  another  a  careful  and  determined  attempt  is 
made  to  rid  the  operation  area  of  every  trace  of  diseased 
tissue.  The  part  is  now  well  washed  with  a  carbolic  solu- 
tion— 1  in  4-0 — and  caref"lly  dried. 


EXCISION  OF  KNEE. 


687 


Nothing  remains  but  to  close  the  wound  Avith  sutures — 
silkwonn  gut  being  the  best  for  the  purpose — and  to  adjust 
the  limb  upon  the  splint  which  has  been  prepared  for  it. 

The  question  of  uniting  the  bony  surfaces  by  means  of 
Avires  or  ivory  pegs  is  considered  afterwards  (page  689). 

A  drainage-tube  is  introduced  into  the  posterior  angle  of 
the  wound  on  either  side ;  or  a  single  tube  may  be  passed 
behind  the  bones,  and  be 
made  to  traverse  the  depths 
of  the  wound  from  one  side  to 
the  other. 

The  sutures  should  not  be 
introduced  until  after  the 
limb  has  been  fixed  upon  the 
splint,  so  that  up  to  the  last 
moment  the  surgeon  may  be 
able  to  satisfy  himself  that 
the  bones  are  in  proper  posi- 
tion. 

The  drainage  -  tubes  will 
be  inserted  before  the  limb  is 
adjusted  to  the  apparatus. 

No  blood-vessels  of  any 
importance  are  divided.  The 
arteries   actually  severed  will 

be  branches  of  the  articular  arteries,  of  the  anastomotica 
magna,  and  of  the  anterior  tibial  recurrent.  Continued  press- 
ure with  a  dry  sponge  will  be  sufficient  to  check  such  bleed- 
ing as  is  usually  met  with. 

Comment. — Neither  a  tourniquet  nor  Esmarch's  elastic 
band  is  required  in  this  operation. 

The  knife  used  should  be  rounded  at  the  point. 

In  the  majority  of  instances  it  is  possible  to  leave  the 
posterior  ligament  undisturbed,  in  which  case  a  substantial 
barrier  remains  that  will  prevent  the  spread  of  suppuration 
into  the  popHteal  space  should  pus  be  produced. 

In  any  case,  care  should  be  taken  to  spare  this  Hgament, 
and  to  separate  its  attachments  from  the  bones  rather  than 
to  cut  it. 

With  regard  to  the  patella,  no  great  good  can  result  from 


Fig.  207. — EXCISION  OF  the  knee  :  the 

SAWING   OP  THE   TIBIA. 


688  OPERATIVE    SURGERY. 

its  retention.  If  partly  diseased,  and  the  morbid  parts  be 
removed,  there  is  still  a  fear  of  the  mischief  reappearmg  and 
extending.  If  apparently  sound  at  the  time  of  the  operation, 
it  may,  if  left,  become  attacked  by  destructive  intiammation 
during  the  healing  process. 

The  retention  of  the  bone  and  of  the  patellar  ligament  does 
not  assist  m  retaining  the  femur  and  tibia  in  position,  inas- 
much as  the  ligament  becomes  loose  and  relaxed  when  the 
limb  is  adjusted  upon  the  splint. 

Since  firm  anchylosis  is  aimed  at  after  the  operation,  the 
quadriceps  muscle  is  of  Httle  value,  and  it  has  not  been 
shown  that  the  retention  of  the  patella  has  increased  the 
usefulness  of  the  limb. 

It  is  better,  therefore,  to  remove  the  bone  in  any  case,  and 
in  effecting  its  excision  it  should  be  carefully  dissected  out, 
and  aU  the  fibrous  tissue  around  it  be  preserved,  provided 
such  tissue  be  free  from  disease. 

The  internal  limit  of  the  incision  should  not  be  carried 
backwards  beyond  the  point  indicated,  in  case  the  internal 
saphenous  vein  and  nerve  be  wounded. 

The  utmost  care  must  be  taken  to  respect  the  epiphysis 
in  young  subjects.  If  damaged,  it  will  lead  to  a  shortened, 
deformed,  and  possibly  useless  limb. 

The  femur  and  tibia  should  be  sawn  from  before  back- 
wards. The  best  instrument  is  a  wide-bladed  thin  saw  with 
a  movable  back.  In  the  hands  of  some  surgeons  a  Butcher's 
saw  appears  to  be  more  convenient.  There  is  no  real  danger 
of  wounding  the  popHteal  vessels  in  sawing  the  tibia  if 
reasonable  care  be  exercised,  and  there  is  consequently  no 
need  to  adopt  the  somewhat  difficult  manoeuvre  of  sawing 
that  bone  from  behind  forwards. 

The  precise  manner  in  which  the  femur  is  sawn  is  of 
primary'  importance.  If  the  section  be  not  made  as  directed, 
the  bones  may  not  come  well  together,  a  subsequent  dis- 
placement would  be  encouraged,  while  the  best  conditions 
are  not  provided  for  securing  firm  anchylosis.  On  the  other 
hand,  the  limb  may  assume  the  deformed  position  of  either 
knock -knee  or  bow-knee. 

In  adjusting  the  bones  the  two  surfaces  should  ije  made 
to  come  accurately  and  evenly  together,  and  in  bringing  them 


EXGISIOX  OF  KNEE.  689 

into  position  care  must  be  taken  not  to  pinch  the  relaxed 
posterior  Hgament  between  the  liinder  margins  of  the  freshly- 
cut  femur  and  tibia. 

The  limb  should  be  so  disposed  as  to  be  absolutely  straight, 
and  the  position  of  slight  flexion  advised  by  some  is  distinctly 
to  be  condemned. 

In  the  final  scraping  away  of  the  diseased  soft  parts/ 
especial  care  must  be  taken  to  fully  expose  and  evacuate  the 
supra-patellar  synovial  pouch. 

With  regard  to  the  fixing  of  the  bones  with  metallic 
sutures  or  pegs,  it  must  be  observed  that  such  a  measure 
effects  its  object  but  feebly,  that  primary  healing  is  apt  to 
be  hindered,  that  the  subsequent  removal  of  the  wires  or  pegs 
may  be  difficult,  and  that  the  presence  of  these  foreign  bodies 
may  excite  some  carious  mischief  in  the  bones. 

If  a  really  suitable,  strong,  and  well-adjusted  apf)aratus 
be  used  to  fix  the  limb,  the  employment  of  the  means  just 
named  becomes  quite  unnecessary. 

The  introduction  of  the  use  of  metallic  sutures  in  this 
operation  is  ascribed  to  Dr.  Buck,  of  New  York. 

The  use  of  pegs  is,  however,  advised  by  some  eminent 
and  practical  surgeons,  and  notably  by  Mr.  Howard  Marsh. 
He  comments  upon  this  measure  in  the  following  words 
("  Diseases  of  Joints,"  page  330) : — 

"  A  method  which  greatly  assists  in  keeping  the  fragments 
in  apposition,  and  therefore  still  further  enables  the  surgeon 
to  dispense  with  circular  constriction  of  the  thigh,  is  that  of 
pegging  the  bones  together,  introduced  by  Mr.  Baker,  of  St. 
Bartholomew's  Hosj)ital.  Mr.  Baker  employs  two  steel  pins 
about  the  size  of  knitting-needles.  These  are  passed,  one  on 
the  inner  and  the  other  on  the  outer  side  of  the  limb,  throusfh 
the  skin  into  the  tibia,  and  on  for  about  an  inch  and  a  half 
into  the  femur.  They  are  removed  (an  easy  matter,  as  their 
ends  are  left  projecting)  on  the  tenth  to  the  twelfth  day.  Mr. 
Willett  prefers  bone  pegs,  Avhich  are  cut  off  short  and  allowed 
to  remain.  I  have  used  these  bone  pegs  in  six  cases.  They 
certainly  fix  the  ends  of  the  bones  in  a  very  satisfactory 
manner.  I  have  allowed  the  ends  to  project,  and  have  left 
them  in  place  for  a  month,  till  all  chance  of  movement 
between  the  bones  has  passed  by. 


690  OPERATIVE    SURGERY. 

"  In  some  instances  I  have  found  the  pegs  by  this  time 
so  firmly  held  that  I  could  not  withdraw  them,  and  I  have 
therefore,  cut  them  short  and  left  them ;  others  have  been 
loose,  and  have  been  easily  removed." 

With  regard  to  the  general  circumstances  of  the  operation. 
Mr.  Jacobson  {"  The  Operations  of  Surgery,"  page  1013)  writes . 
"  Before  and  throughout  an  excision  of  the  knee,  the  operator 
should  bear  in  mmd  the  folloAving  points  : — (1)  To  remove 
every  atom  of  the  disease ;  (2)  to  secure  good  drainage ;  (3) 
to  leave  the  bones  in  good  position ;  (4)  to  ensure  absolute 
immobility  afterwards ;  (5)  to  watch  for  and  at  once  attack 
an}^  relapse.  .  .  .  Before  the  time  of  the  excision,  any 
flexion  of  the  knee  should  be  corrected,  as  far  as  possible, 
by  careful  weight  extension.  A  knee  should  never  be  excised 
while  flexed.  Such  a  step  ^vill  not  only  be  liable  to  lead  to  re- 
moving bone  needlessly  in  order  to  straighten  it,  but  stretch- 
ing the  contracted  deep  fascia  and  nerves  may  lead  to  tetanus. 
The  risk  of  gangrene  has  also  been  already  mentioned." 

2.  Other  Methods  of  Excising  the  Knee. 

The  many  operations,  with  which  the  names  of  as  many 
surgeons  are  associated,  differ  but  httle  from  one  another 
except  in  the  matter  of  the  skin  incision. 

A.  Park  employed  a  species  of  crucial  incision  (Fig.  205,  b), 
which  has  met  with  few  imitators. 

B.  An  anterior  U-shaped  flap  was  introduced  by  Mac- 
kenzie, and  has  been  extensively  adopted  by  English  and  other 
surgeons.  The  smaller  of  the  so-called  flaps  is  but  a  slight 
modification  of  the  transverse  curved  incision  above  described. 
The  larger  form  of  flap  had  its  base  on  a  level  with  the  upper 
limits  of  the  femoral  condyles,  and  its  apex  or  free  end 
opposite  the  tubercle  of  the  tibia  (Fig.  208,  a). 

This  flap  is  unnecessarily  large,  and  involves  a  very  ex- 
tensive wound. 

c.  Moreau  employed  an  H -shaped  incision,  which  was 
accepted  by  many  of  the  earlier  operators  with  certain  more 
or  less  insignificant  modifications. 

One  form  of  incision  employed  by  Oilier  reverts  to  this 
early  method  of  dividing  the  skin  (P'ig.  208,  b).  Oilier  attempts 
to  carry  out  the  excision  as  far  as  possible  upon  the  subperi- 
osteal plan ;  but  the  anatomy  of  the  joint,  and  the  conditions 


EXCISION  OF  KNEE. 


()01 


Langenbcck 
cut  some  five  inches  in  length 


under  which  the  operation  is  usually  performed,  do  not  lend 
themselves  to  this  method,  which  is,  indeed,  distinctly  un- 
suited  to  this  part  of  the  body.  Even  if  carried  out  precisely 
upon  the  lines  laid  down  by  Oilier,  it  is  still  incomplete.  An 
extensive  arthrectomy  is  the  nearest  approach  to  a  sub- 
periosteal operation. 

D.  Longitudinal  incisions  are  employed  by  some  surgeons 
The  incision  may  be  median,  and  the  patella  either  turned 
aside   or   split   vertically,   and   then 

united  by  suture  after  the  operation 
is  completed. 

employs  a  vertical 
which 
is  situated  upon  the  antero-internal 
aspect  of  the  joint.  The  knife  divides 
the  vastus  internus  half-way  between 
the  inner  edge  of  the  patella  and  the 
internal  condyle,  and  is  arrested 
opposite  to  the  inner  tuberosity  of 
the  tibia. 

The  bones  are  dislocated  inwards, 
and  removed. 

Jeffray,  Sedillot,  and  William 
Knight  Treves  employed  two  vertical 
lateral  incisions,  dividing  the  bones 
by  means  of  a  chain-saw  or  a  very 
narrow  hand- saw. 

These    operations    by   means    of 
longitudinal  incisions   were   for   the 
most   part   designed   with   the   pur- 
pose of  saving  the  patella  and  its  ligament,  and  were  founded 
upon  the  beHef  that  the  preservation  of  those  structures  was 
of  primary  importance  in  the  future  utiHty  of  the  limb. 

The  method  by  a  longitudinal  incision  is  difficult  and 
tedious,  a  small  space  is  provided,  a  good  view  of  the  interior 
of  the  joint  cannot  be  obtained,  the  removal  of  all  the 
diseased  tissue  is  less  surely  effected,  and  good  drainage 
cannot  be  provided  for  unless  a  special  drainage  incision 
be  made. 

E.  Golding   Bird    preserved    the   patella,   but    sawed   it 
s  s  2 


Fiff. 


A,  U-shaped  flap ;   B,  Ollier's 
subperiosteal  method. 


692  OPERATIVE    8UBGEBY. 

through  transversely  to  reach  the  jomt,  and  after  the  excision 
united  the  two  fragments  of  the  bone  together  with  sutures. 
Dr.  Fenwick,  of  Montreal,  saws  both  femur  and  tibia  in  a 
curved  hne,  "so  as  to  make  them  fit  together  more  closely 
xmd  accurately  than  they  would  do  otherwise." 

There  is  nothing  to  recommend  this  operation,  while  many 
very  cogent  arguments  may  be  urged  against  it. 

After-treatment. — The  after-treatment  is  of  the  utmost 
importance,  is  tedious,  and  often  surrounded  with  difficulties. 
There  is  a  tendency  to  displacement,  and  notably  to  a  dis- 
placement of  the  tibia  backwards.  If  sound  healing  do  not 
take  place,  the  limb  is  worse  than  useless,  and  the  flail-like 
limb  that  may  result  is  of  less  service  to  the  patient  than  a 
good  artificial  leg. 

The  limb  must  be  put  up  perfectly  straight — i.e.,  in 
the  position  of  complete  extension — and  for  the  purpose  of 
fixing  it  many  surgeons  employ  plaster-of-Paris.  The  rigid 
dressing  formed  of  this  material  is  not  entirely  satisfactory. 
It  may  exercise  an  unequal  pressure  upon  the  parts,  and  may 
lead  to  oedema,  etc.  Discharge  may  find  its  way  between  the 
splint  and  the  limb,  the  dressing  is  difficult  to  remove,  and 
even  when  large  "  windows "  are  provided  the  inspection  of 
the  part  can  never  be  so  complete  as  it  should  be. 

Such  a  splint  should  be  provided  as  will  allow  the  .bones 
to  be  kept  in  good  position,  will  permit  of  a  free  inspection 
and  examination  of  the  wound,  and  will  not  interfere  with 
dressing  and  drainage. 

It  is  weU  that  the  splint  should  be  suspended. 

Mr.  Howard  Marsh  points  out  that  "  the  plan  of  firmly 
bandaging  the  lower  end  of  the  femur  to  the  back  spHnt  leads 
to  great  sweUing  about  the  wound,  and  materially  retards 
repair.  It  is  apt,  also,  to  induce  persistent  venous  oozing 
after  the  operation."  To  avoid  these  drawbacks,  he  employs 
Gant's  splint.  This  simple  splint,  instead  of  binding  the 
femur  down  to  the  level  of  the  tibia,  brings  the  tibia  up 
to  the  level  of  the  fenun-,  and  no  tight  bandaging  is  called 
for. 

Another  splint  which  answers  admirably  in  the  after- 
treatment  of  excision  of  the  knee  is  Howse's  splint  (described 
in  Guy's  Hospital  Report,  1877,  page  503). 


EXCISION  OF  FEMUR.  693 

Not  a  few  of  the  splints  employed  have  the  disadvantage 
of  being  complex,  and  difficult  to  adjust. 

Dry  dressings  should  be  applied  to  the  wound. 

The  limb  must  be  kept  upon  the  splint  until  it  is  sound. 
This  period  will  vary  from  six  weeks  to  three  months.  Com- 
plete recovery  can  usually  not  be  expected  until  six  months 
have  elapsed. 

After  the  splint  has  been  removed,  a  light  leather  support, 
strengthened  with  a  strip  of  steel  at  the  back,  should  be 
applied  ;  and  in  the  case  of  children  Mr.  Jacobson  advises  that 
such  a  support  should  be  worn  for  three  or  more  years. 

A  thick-soled  boot  will  be  required  to  meet  the  inevitable 
shortening. 

Results. — The  results  in  very  young  children  (under  five 
years  of  age)  have  been  bad,  and  the  same  may  be  said  of 
patients  over  thirty.  Excision  of  the  knee  in  adults  over 
forty  has  been  attended  with  very  bad  results. 

The  mortality  of  excision  for  disease  is  about  20  to  25  per 
cent. ;  of  excision  for  injury,  about  40  per  cent. ;  and  of  ex- 
cision for  gunshot  wounds,  about  80  per  cent. 

The  best  result  is  obtained  when  firm  anchylosis  follows. 
Deformed,  stunted,  and  flail-like  limbs  are  common  after  this 
operation ;  and  when  the  excision  has  been  performed  for 
tubercular  disease,  a  relapse  is,  unfortunately,  not  uncommon. 

EXCISION   OF   THE   FEMUR. 

Excisions  of  portions  of  the  femur,  apart  from  the  removal 
of  large  sequestra,  are  very  rarely  indeed  carried  out. 

In  the  treatment  of  gunshot  injuries  it  would  appear 
that  these  operations  are  attended  by  a  mortality  of  nearly 
70  per  cent.  (Otis).  In  acute  bone  disease  the  indications  for 
an  excision  operation  are  seldom  clear,  and  better  methods  of 
dealing  with  ununited  fracture  of  the  shaft  have  been  devised. 

To  reach  the  shaft  of  the  bone  the  incision  should  be 
made  upon  the  outer  side  of  the  limb,  and  be  carried  down  to 
the  bone  between  the  vastus  externus  and  the  short  head  of 
the  biceps  muscle. 


694 


CHAPTER    XIX. 

Excision    of    the    Hip. 

This  operation  usuall}''  implies  the  removal  merely  of  the 
upper  end  of  the  femur,  and  the  scraping  away  of  any 
diseased  tissue  which  may  occupy  the  acetabulum.  As  hi  the 
case  of  the  shoulder-joint,  so  here  also  the  excision  does  not 
involve  the  whole  joint  and  the  entire  articulating  surfaces. 

The  value  of  the  operation,  the  conditions  under  which  it 
should  be  performed,  and  the  character  of  the  results  obtained, 
have  been,  and  still  are,  subjects  upon  which  the  most  diverse 
opinions  are  held. 

It  may  be  assumed,  in  the  first  place,  that  excision  of  the 
hip  is  usually  performed  for  chronic  suppurative  joint  disease 
occurring  in  young  subjects.  In  all  but  a  quite  small  pro- 
portion of  the  cases  the  mischief  is  tubercular. 

The  age  between  six  and  fourteen  is  considered  to  be  the 
best  for  the  operation,  and  few  even  of  those  who  practise 
excision  extensively  would  carry  out  this  measure  in  patients 
over  sixteen  years  of  age.  One  or  two  surgeons  have  ex- 
pressed the  opinion  that  the  operation  should  never  be  per- 
formed in  patients  under  the  age  of  ten. 

Mr.  Howard  Marsh  is  very  adverse  to  the  operation 
("  Diseases  of  the  Joints,"  1886).  He  considers  that  the  treat- 
ment by  continued  rest  provides  such  admirable  results  (re- 
covery with  but  slight  lameness  and  but  slight  loss  of  move- 
ment in  70  per  cent,  of  the  cases,  and  a  mortahty  of  about 
5  per  cent.)  that  the  conditions  which  would  sanction  excision 
are  exceedingly  few.  Even  Avhen  suppuration  has  occurred, 
he  would  not  place  the  mortality  above  6  or  8  per  cent. 

He  considers  that  operation  in  the  early  stage  of  the 
disease  is  unjustifiable,  and  that  in  very  advanced  disease  the 
excision  will  be  of  doubtful  benefit. 

Mr.  Wright,  on  the  other  hand,  is  strongly  in  favour  of  the 


EXCISIOX  OF  Ilir.  695 

operation,  and  considers  that  it  should  be  performed  early — 
at  least,  as  soon  as  there  is  any  evidence  of  external  abscess 
("  Hip  Disease  in  Childhood  ").  Mr.  Wright  has  performed 
excision  in  over  one  hundred  cases,  while  at  the  London 
Hospital  only  four  excisions  of  the  hip  have  been  performed 
in  four  years. 

Mr.  Barker, in  his  "  Himterian  Lectures"  (1888),  advocates 
with  some  reserve  excision  in  the  early  stages  of  the  disease, 
and  considers  that  the  cases  of  advanced  mischief  in  the  joint 
are  unsuitable  for  excision.  The  method  of  ojjerating  advised 
by  Mr.  Barker  (page  703)  has  been  attended  with  considerable 
success. 

The  usefulness  of  the  limb  obtained  after  excision  has  also 
been  the  subject  of  considerable  difference  of  opinion. 

Into  this  very  w4de,  compUcated,  and  vexed  question  it  is 
impossible  here  to  enter.  It  is  only  necessary  to  point  out 
that  the  position  of  this  operation  cannot  yet  be  considered 
to  be  fully  established,  and  it  may  be  suggested  that  the  truth 
will  be  found  to  be  in  a  course  midway  between  the  two  very 
adverse  modes  of  practice  to  which  allusion  has  just  been 
made. 

Excision  of  the  hip  for  gimshot  injury  has  been  attended 
with  a  terrible  mortality.  Otis's  statistics  show  a  death  rate 
of  90-9  per  cent.  The  same  statistics,  however,  show  that  in 
the  cases  treated  by  conservation  the  mortahty  was  98 "8  per 
cent.,  and  in  those  treated  b}^  amputation  it  was  83  3  per  cent. 
•  The  excisions  at  one  time  practised  for  anchylosis  in  a  bad 
position  have  been  replaced  by  osteotomy. 

Excision  of  the  hip  was  first  suggested  by  Charles  White, 
of  Manchester,  in  1709.  It  was  tirst  performed  by  Anthony 
White,  of  the  Westminster  Hospital,  in  1818.  The  operation 
was  carried  out  on  a  boy  of  14  to  remedy  the  result  of  long- 
standing hip  disease.  Four  inches  of  the  femur  were  removed. 
A  good  recovery  followed. 

The  operation  was  but  seldom  practised  until  the  time  of 
Sir  William  Fergusson,  who  did  much  to  bring  the  measure 
into  general  use  {Med.-Ghir.  Trans.,  1845). 

Within  recent  times  the  operation  has  perhaps  been  some- 
what too  extensively  and  too  indiscriminately  practised :  and 
after  a  reaction  m  the  opposite  dii-ection  of  condemning  the 


696  OVERATIVE    ^SURGERY. 

operation  altogether  has  passed  away,  the  true  use  and  position 
of  the  excision  will  no  doubt  be  established. 

Anatomical  Points.— The  hip-joint  is  deeply  placed,  and 
is  surrounded  by  numerous  muscles.  In  front  are  the  psoas 
and  iliacus ;  behind,  the  quadratus  femoris,  the  obturator 
mternus,  the  two  gemelh,  and  the  pyriformis  ;  on  the  outer 
side  are  the  gluteus  medius  and  minimus  and  the  rectus ;  and 
on  the  inner  side  are  the  pectineus  and  obturator  externus. 

The  capsule  of  the  joint  is  exceedingly  strong,  and  forms 
indeed  the  strongest  hgament  in  the  body. 

The  thickest  parts  of  the  capsule  have  received  the  names 
of  the  ilio-femoral,  the  ischio-femoral,  and  the  pubo-femoral 
ligaments.  The  capsule  is  thinnest  between  the  ilio-femoral 
and  pubo-femoral  ligaments,  and  here  the  synovial  sac  often 
communicates  with  the  bursa  which  lies  beneath  the  psoas 
muscle  at  this  spot.  The  capsule  is  also  weak  where  covered 
by  the  obturator  muscles. 

The  upper  border  of  the  great  trochanter  is  on  a  level  with 
the  centre  of  the  hip-joint.  A  line  (Nelaton's  line)  drawn 
from  the  anterior  superior  iliac  spine  to  the  most  prominent 
part  of  the  tuber  ischii  will  cross  the  centre  of  the  acetabulum 
and  will  hit  the  top  of  the  gi-eat  trochanter. 

The  head  of  the  femur  lies  close  below  Poupart's  ligament, 
and  just  to  the  outer  side  of  its  central  point. 

The  position  of  the  chief  bursEe  about  the  hip-joint  should 
be  borne  in  mind. 

Ossification  commences  in  the  head  of  the  femur  ten 
months  after  birth,  in  the  great  trochanter  in  the  fourth  year, 
and  in  the  lesser  trochanter  in  the  thirteenth  year.  The  last- 
named  process  of  bone  joins  the  shaft  at  the  age  of  eighteen, 
the  great  trochanter  joins  about  eighteen  and  a  half,  and 
the  head  about  the  nineteenth  year.  The  neck  is  ossified 
by  an  extension  from  the  diaphysis,  and  this  upper  (Ex- 
tremity of  the  shaft  serves  to  separate  the  head  from  the 
two  trochanters. 

The  acetabular  element  of  the  os  innominatum  ossifies  in 
the  sixth  year  from  one  or  more  centres  which  appear  in  the 
Y-shaped  cartilage. 

The  bone  so  produced  joins  Avith  the  ilium  and  the 
ischium  at  the   age  of  fourteen,  and  with   the  os  pubis  at 


EXCISION  OF  IIIF.  697 

fifteen.     The  ossification  of  the  acetabulum  is  completed  at 
about  the  age  of  seventeen  years. 

The  shortening  which  follows  upon  removal  of  the  upper 
end  of  the  femur  in  a  young  subject  is  much  less  than  would 
be  expected.  Indeed,  such  diminution  of  length  as  follows 
would  appear  to  be  due  rather  to  the  actual  loss  of  bone,  to 
some  possible  displacement  of  the  upper  end  of  the  femur, 
and  to  the  general  atrophy,  which  is  marked  in  the  entire 
extremity.  The  principal  increase  in  the  femur  is  effected  by 
the  lower  epiphysis.  Little  growth  is  accomplished  by  the 
upper.  A  main  feature  in  the  shortened  limb  after  hip 
disease  is  certainly  due  to  a  general  arrest  of  development 
in  the  entire  limb. 

THE   OPERATION. 

The  following  methods,  most  usually  employed  at  the 
present  day,  will  be  described  with  such  comments  as  bear 
upon  their  comparative  advantages  and  disadvantages  : — 

1.  By  an  external  incision  (Langenbeck's  operation). 

2.  By  the  subperiosteal  method. 

3.  By   an    anterior  incision    (Liicke's    operation    and 

Barker's  operation). 
4  By  a  posterior  incision. 

1.  By  an  External  Incision  (Langenbeck's  Operation). 

The  patient  lies  upon  the  sound  side,  with  the  thigh  flexed 
at  an  angle  of  45  degrees,  and  rotated  a  little  inwards. 

The  surgeon  stands  to  the  outer  side  of  the  limb.  An 
assistant  at  the  foot  of  the  table  holds  the  leg,  and  manipulates 
the  extremity  as  required.  A  second  assistant  stands  on  the 
opposite  side  of  the  table  facing  the  surgeon,  and  attends  to 
the  sponging,  etc.  A  third  assistant  may  take  his  place  close 
to  the  patient's  trunk  and  by  the  operator's  side.  He  can 
assist  with  the  retractors. 

(1)  The  Incision. — A  straight  incision  about  four  or  four 
and  a  half  inches  in  length  is  made  in  the  long  axis  of  the 
limb,  and  over  the  outer  surface  of  the  great  trochanter.  It 
falls  a  little  behind  the  middle  of  that  process,  and  in  the 
position  in  which  the  Hmb  is  placed  would  fall  upon  a  line 
directed  doA\Tiwards  from  the  posterior  superior  iliac  spine  to 
follow  the  long  axis  of  the  femur.     Two-thirds  of  the  incision 


€98 


OPERATIVE    SUBGEBY. 


will  lie  over  the  ilium,  and  one-third  over  the  great  trochanter 

and  femur. 

The  upper  extremity  of  the  wound  will  be  about  opposite 

to  the  superior  margin  of  the  great  sciatic  notch  (Fig.  209). 
(2)  The  OjJening  of  the  Joint. — The  knife  is  carried  directly 

down  to  the  bone  and  the  capsule  of  the  hip-joint. 

The  knife   therefore   divides   the   glutei   muscles   in   the 

direction  approximately  of  their  fibres.     The  wound  ma}^  be 

enlarged  if  needed.  The 
capsule  is  opened  in  the 
line  of  the  skin  incision. 
It  is  also  divided  trans- 
versely, close  to  the 
acetabulum,  so  that  the 
section  of  the  ligament 
is  T-shaped. 

By  cutting  the  cotyl- 
oid ligament  air  is  ad- 
mitted into  the  joint, 
and  the  femur  becomes 
separated  fi'om  the  ace- 
tabulum. The  condition 
of  the  bones  can  now 
be  ascertained  with  the 
finger. 

The  muscles  attached 
to  the  great  trochanter 


Fig, 


209. — excision    of    the    hip  : 
beck's  exteenai.  incision. 


^^^'  are  now  divided  close  to 
their  insertion  into  that 
bone.  The  Hmb  is  rotated  inwards,  in  order  to  expose  the 
connections  of  the  posterior  muscles,  and  rotated  outwards 
to  reach  and  divide  the  anterior  muscles. 

The  ligamentum  teres  will  probably  have  disappeared ;  if 
not,  it  must  now  be  severed. 

(3)  The  Application  of  the  Saw. — The  head  of  the  bone 
is  dislocated  backwards,  and  thrust  as  far  as  convenient  into 
the  wound.  While  the  soft  parts  are  protected  by  means  of 
retractors  and  spatulse,  the  surgeon  divides  the  upper  end  of 
the  femur  by  means  of  a  narrow  saw. 

Such  arterial  twigs  as  bleed  can  probably  be  secured  by 


EXCISION  OF  HIP.  699 

means  of  pressure  forceps,  and  the  application  of  a  ligature 
to  an}'  vessel  will  seldom  be  required. 

The  surgeon  finally  removes,  with  the  gouge  or  chisel,  any 
diseased  bone  Avhich  may  be  found  in  the  acetabulum. 

With  the  sharp  spoon  he  then  proceeds  to  scrape  out  the 
cavity  of  the  joint,  and  to  remove  any  traces  of  diseased 
synovial  tissue  which  may  be  left.  Sinuses  are  scraped  and 
opened  up.  The  joint  is  well  washed  out  with  a  carbolic 
solution — 1  in  40 — and  is  then  well  dried  with  the  sponge. 

The  sutures  are  inserted,  and  a  drainage-tube  introduced. 

Comment. — No  Esmarch's  tourniquet  is  required  in  this 
or  any  other  method  of  excising  the  hip. 

If  the  head  of  the  femur  be  dislocated  upon  the  dorsum, 
the  incision  will  have  to  be  a  little  modified.  It  may  be  made 
small  at  first,  and  enlarged  as  required. 

In  young  subjects  the  cartilaginous  tissue,  of  which  the 
great  trochanter  is  still  in  part  composed,  may  be  peeled  off 
with  the  muscles,  the  rugine  being  used  instead  of  the  knife. 

During  the  sawmg  of  the  femur  care  should  be  taken  to 
disturb  the  periosteum  as  httle  as  possible. 

The  head  of  the  bone  may  be  steadied  by  means  of  the 
lion  forceps  while  being  sawn. 

The  actual  amount  of  bone  removed  fi-om  the  femur  must 
depend  mainly  upon  the  extent  of  the  disease.  This,  however, 
is  not  the  sole  consideration,  and  upon  this  point  the  opinion 
of  Mr.  Jacobson  may  be  expressed : — "  I  think  that  the  section 
through  the  great  trochanter  {i.e.,  just  below  its  upper  margin) 
is  preferable  to  one  above  it  (i.e.,  through  the  neck).  This 
has  the  advantages  of  disturbing  and  damaging  the  attach- 
ments of  muscles  much  less,  and  thus  leads  to  more 
rapid  healing  and  far  greater  mobility  of  the  limb.  These, 
however,  are  outweighed  b}'  the  disadvantage  which  leaving 
such  a  large  piece  of  bone  as  the  trochanter  entaUs — viz.,  that 
after  healing,  this  process  gets  drawn  up  against  the  scar  and 
constantly  frets  it.  It  is  also  said  to  check  the  escape  of 
discharges,  and  to  render  the  patient  liable  to  persistence  or 
recurrence  of  the  disease.  I  am  doubtful  as  to  the  last  two, 
but  the  first  is  absolutely  certain "  ("  The  Operations  of 
Surgery,"  page  973). 

Mr.  Barker  is  not  disposed  to  admit  the  objections  which 


700  OPERATIVE    SURGERY. 

have  been  urged  against  the  retention  of  the  trochanter,  and 
advises  that  under  any  circumstances  as  httle  bone  should 
be  taken  awa}^  as  possible,  compatibly  with  thorough  removal 
of  the  diseased  portions. 

This  operation  follows  very  emphatically  the  hnes  of  the 
"  open  method,"  and  is  a  little  crude  and  a  little  regardless 
of  the  tissues  in  the  vicinity  of  the  joint. 

It  may  claim  to  be  easy  and  safe.  The  bone  is  well  and 
readily  exposed,  and  is  very  easily  sawn. 

Good  drainage  is  allowed  for. 

The  disadvantages  of  the  method  are  the  following  : — Many 
large  and  important  muscles  are  cut  through,  and  the  stability 
of  the  new  joint  possibly  weakened  thereby.  The  soft  parts 
are  exposed  to  much  handling  and  some  bruising.  Many  of 
the  arteries  which  meet  about  the  great  trochanter  are  divided. 
A  transverse  section  is  made  of  the  capsule,  and  the  strength 
of  that  ligament  is  consequently  weakened. 

2.  By  the  Subperiosteal  Method. 

(1)  The  Incision,  and  the  Exposure  of  the  Neck  of 
the  Femur. — The  incision  is  precisely  similar  to  that  just 
described ;  and  the  positions  of  the  patient,  of  the  limb,  and 
of  the  surgeon,  are  identical  with  those  observed  in  the  previous 
operation.  The  skin  and  subcutaneous  fat  are  divided,  and 
the  part  of  the  gluteus  maximus  muscle  which  is  exposed 
is  severed  in  the  line  of  the  skin  incision,  and  the  gap  thus 
made  in  the  muscles  is  widened  by  means  of  suitable  retractors 
(Fig.  210).  The  surgeon  now  seeks  with  the  linger  for  the  gap 
between  the  gluteus  medius  (in  front  and  above)  and  the 
pyriformis  (behind  and  below).  These  two  muscles  are 
separated  from  one  another,  and  in  the  gap  between  them  and 
in  the  Hne  of  the  original  incision  the  knife  is  carried  down 
to  the  great  trochanter,  the  periosteum  of  which  is  divided 
(Fig.  210). 

Now  with  one  broad  retractor  the  gluteus  medius  is  drawn 
forwards  and  the  pyriformis  backwards,  and  the  capsule,  which 
is  tliereby  exposed,  is  divided  with  the  laiife  in  the  long  axis 
of  the  femoral  neck. 

Passing  through  the  capsule,  the  surgeon  divides  the 
periosteum  of  the  neck  in  the  saine  line,  and  continues  this 
j)eriosteal  incision  downwards  over  tlie  upper  margin  of  the 


■^ 


EXCISION  OF  HIP. 


701 


trochanter  to  join  tlie  incision  already  made  in  the  membrane 
covering  that  process  (Fig.  211). 

The  part  is  now  ready  for  the  rugine. 

2.  The  Anterior  Capstdo-Periosteal  Flap. — With  the 
rugine  the  surgeon  now  separates  the  periosteum  from  the 


Fig.  210. —EXCISION  OP  THE   HIP  BY  AN   EXTEENAl  INCISION. 

A,  Gluteus  maximus ;  B,  Gluteus  medius  at  the  great  trochanter  ;   c,  Pyriformis. 
{After  Farabeuf. ) 


neck  and  the  great  trochanter,  turning  it  forwards  and  baclv- 
wards  in  the  form  of  two  flaps.  To  complete  these  triangular 
flaps  the  periosteum  is  divided  transversely  along  the  line  at 
which  the  neck  of  the  femur  ioins  the  articular  cartila2"e  of 
the  head.  The  thigh  is  flexed  and  rotated  outwards,  and 
working  the  rugine  from  above  downwards  and  from  behind 
forwards,  the  inner  part  of  the  neck  and  of  the  trochanter  are 
laid  bare.  In  this  stage  of  the  operation  the  insertions  of  the 
gluteus  medius  and  gluteus  minmius,  and  of  the  Y-shaped 
ligament,  are  separated  from  the  bone,  together  with  the 
periosteum. 


702 


OPERATIVE    SURGERY. 


E-- 


A_. 


(3)  The  Posterior  Capsido-Periosteal  Flap. — The  thigh 
is  now  less  flexed,  is  adducted  and  rotated  inwards.  The 
rueine  is  used  from  above  downwards  and  from  before  back- 
wards,  and  the  periosteum  is  elevated  from  the  outer  part  of 
the  neck,  from  the  digital  fossa,  and  from  the  posterior  part  of 
the   trochanter.     With  it  is  separated  more  of  the  capsule 

and  the  attach- 
ments of  the 
obturators,  the 
gemelli,andthe 


pyriformis. 

4.  The  Re- 
moval of  the 
Upper  End  of 
the  Femur. — 
The  head  of 
the  bone  is  dis- 
located back- 
wards, and 
when  free  of 
the  acetabulum 
the  rugine  is 
used  to 
all  the 
rem  aming  peri- 
osteum, with  the  remaining  attachments  of  the  capsule,  from 
the  neck  of  the  femur.  As  this  is  being  done,  the  periosteum 
along  the  line  of  its  termination  at  the  articular  head  is 
divided. 

The  thigh  is  flexed  and  adducted,  and  while  the  head  is- 
steadied  with  lion  forceps  and  the  soft  parts  are  protected  by 
spatuke,  the  upper  end  of  the  bone  is  sawn  through  as  far 
down  as  it  has  been  laid  bare. 

Any  disease  of  the  acetabulum  is  dealt  with  in  the  usual 
way,     A  drain  is  introduced,  and  the  sutures  are  inserted. 

Comment. — This  procedure  is  excellent  in  theory,  but  it 
can  be  of  most  limited  application  in  practice. 

Sir  Wm.  MacCormac  is  of  opinion  that  the  subperiosteal 
method  may  be  carried  out  in  children,  and  in  cases  of 
secondary  resection  after  injury,  but  that  it  is  impracticable 


Fig.  211. — EXCISION   OF   THE   HIP   BY  AIST  EXTEENAL  INCISION. 

A,   Gluteus  maximus  ;    B,    Gluteus  medius  ;    C,  Pyriformis ; 
D,  Great  trochantpr  ;  E,  Cajjsule  of  hip- joint.    [Farabeuf.) 


again 
clear 


EXCISION  OF  HIP. 


703 


where  excision  is  performed  for  recent  injury  in  the  adult.  In 
the  ordinar}^  affection  for  which  the  operation  is  performed — 
viz.,  tubercular  joint  disease — it  can  seldom  be  desirable  to  pre- 
serve so  much  of  the  intracapsular  periosteum.  It  has  not 
been  clearly  shown  that  the  preservation  of  this  periosteum 
has  had  substantial  effect  upon  the  utility  of  the  hmb  after 
the  operation. 

The  procedure  is  difficult  and  tedious,  and  the  deeper  parts 
of  the  wound  are  so  disposed  as  not  to  favour  drainage.     The 
method  of  dealinsr  Avith  the  trochanter 
is,  in  suitable  cases,  worthy  of  adoption. 

3.  By  an  Anterior  Incision. 

Luches  Operation.  —  The  incision 
ill  this  case  consists  of  a  straio-ht  line 
in  the  long  axis  of  the  femur,  and 
from  four  to  five  inches  in  length. 
Commencing  about  half  an  inch  below 
and  to  the  inner  side  of  the  anterior 
superior  iliac  spine,  it  descends  nearly 
vertically  just  to  the  outer  side  of  the 
anterior  crural  nerve  (Fig.  212). 

The  inner  border  of  the  sartorius 
is  exposed,  and  then  the  rectus  and  the 
psoas. 

The  thigh  is  flexed,  adducted,  and 
rotated  out,  the  sartorius  and  rectus 
are  drawn  to  the  outer  side  by  suit- 
able retractors,  and  the  psoas  to  the 
inner  side. 

The  capsule  of  the  joint  is  thus 
exposed,  and  is  incised  vertically. 

The  cotyloid  ligament  is  cut,  the  head  of  the  bone  freed 
and  sufficiently  displaced  to  allow  of  the  saw  being  apphed. 

Barkers  Operation. — This  operation  is  described  in  the 
British  Medical  Journal  (Jan.  19th,  1889).  It  has  been 
attended  with  remarkably  successful  results. 

The  incision  employed  is  that  advised  by  Dr.  Hueter  in 
1878,  and  independently  by  Mr.  R.  W.  Parker  {Clin.  Sac. 
Trans.,  vol.  xiii.). 

The  patient  lies  supine,  with  both  thighs  fully  extended 


Fig.  212. — EXCISION  OF  THE 
HIP  :  LTJCKE'S  ANTEEIOE 
INCISION. 


704  OPERATIVE    SURGERY. 

The  sm'geon  stands  in  every  case  on  the  ri^ht  side  of  the 
patient;  one  assistant,  facing  him,  holds  the  affected  thigh, 
another  stands  beside  and  to  the  left  of  the  operator. 

The  most  precise  and  rigorous  aseptic  measures  are  carried 
out. 

The  incision  commences  on  the  front  of  the  thigh,  half 
an  inch  below  the  anterior  superior  spinous  process  of  the 
ilium,  and  runs  downwards  and  a  little  inwards  for  three 
inches.  As  the  knife  sinks  into  the  Umb  it  passes  between  the 
tensor  vaginae  femoris  and  glutei  muscles  on  the  outside,  and 
the  sartorius  and  rectus  on  the  inside,  until  it  reaches  the 
neck  of  the  femur.  This  incision  does  not  divide  any  muscle 
fibres,  nor  vessels  or  nerves  of  the  slightest  importance. 
It  is  unnecessary  to  carry  the  deeper  part  of  the  incision  to 
the  full  extent  of  the  external  wound.  If  an  abscess  is  opened 
up  before  the  joint  is  reached,  its  contents  are  thoroughl}^ 
flushed  out  with  sterilised  hot  water,  at  a  temperature  of 
between  lOS*-^  and  110*^,  before  anything  further  is  done. 
For  this  purpose  a  large  three-gallon  can  is  used,  which  has 
three  taps  below,  to  each  of  which  six  or  eight  feet  of  india- 
rubber  tubing  is  attached.  This  can  is  placed  some  feet 
above  the  operating  -  table,  so  as  to  have  a  considerable 
pressure  of  water.  Each  of  the  rubber  tubes  terminates  in 
one  of  Barker's  flushing-gouges.  These  instruments  consist  of 
a  gouge  with  a  canal  running  through  the  handle,  so  that  a 
stream  of  water  may  be  directed  into  the  hollow  of  the  gouge. 
The  abscess  having  been  cleared  out  by  means  of  the  msh  of 
hot  water,  aided  by  these  fiushing-gouges,  the  neck  of  the 
femur  is  sawn  across  Avith  a  narrow  saw  in  the  direction  of  the 
external  wound.  The  diseased  head  can  then  be  lifted  out 
by  means  of  the  flushing-scoop  or  a  sequestrum  forceps, 
through  which  the  hot  stream  is  rushing  into  the  joint.  By 
the  time  the  head  of  the  bone  has  been  got  out,  the  Avhole 
cavity  is  comparatively  clean.  Now  begins  the  search  for 
further  disease.  This  can  usually  be  easily  estimated  b}^  the 
left  forefinger,  with  which  the  acetabulum  is  tirst  examined, 
and  then  all  the  other  parts  of  the  joint-cavity.  Wherever 
diseased  material  is  felt,  it  is  cut  away  by  the  flushing-gouge 
or  scoop,  the  hot  water  carrying  away  the  dehris  as  fust 
as  it  is  produced,  and  with  it  all  blood,  while  at  the  same 


EXCISION    OF   HIP.  705 

time  it  arrests  bleeding  from  the  fresh-cut  surfaces.  When 
every  part  of  the  field  of  operation  has  been  gouged  and 
scraped  clean  of  all  tubercular  material,  and  the  water  runs 
away  clear,  the  cavity  is  dried  out  with  carbolised  sponges,  one 
or  two  of  which  are  left  in  it  until  all  the  stitches  are  placed 
in  position.  These,  which  are  of  hard  carboHsed  silk,  should 
dip  deeply,  and  be  placed  close  together.  Just  before  they  are 
tied,  the  sponges  are  removed,  and  with  them  the  last  traces 
of  moisture.  The  wound  is  then  filled  up  with  iodoform 
emulsion,  and  the  sutures  are  tied,  as  much  of  the  emulsion 
being  squeezed  out  at  the  last  moment  as  will  come  away.  A 
little  iodoform  is  now  dusted  over  the  surface  of  the  incision — 
in  which  there  is  no  dramage-tube  in  most  cases — and  the 
whole  joint  is  covered  with  salicylic  wool,  so  adjusted  in  strips 
that  evenly-graduated  pressure  is  brought  to  bear  upon  ever}- 
aspect  of  the  field  of  operation,  while  the  limb  is  held  well 
abducted.  If  the  wool  be  now  firmly  compressed  with  a  spica 
bandage,  the  walls  of  the  whole  clean-scraped  cavity  are 
brought  into  contact,  and  the  remainder  of  the  neck  of  the 
femur  is  thrust  into  the  acetabulum,  and  secured  there. 

Now  when  all  this  has  been  done,  although  there  remains 
potentially  a  cavity,  there  is  actually  nothing  of  the  kind,  for 
all  the  surfaces  have  been  brought  into  apposition.  And  then, 
assuming  that  perfect  asepsis  has  been  observed,  all  these  sur- 
faces ought  to  unite  with  a  minimum  of  plastic  exudation. 
After  the  operation  the  patient  is  at  once  placed  upon  a  double 
Thomas's  splint. 

Comrrient. — Of  these  two  procedures,  the  latter  is  un- 
doubtedly the  better.  In  Lilcke's  operation  the  mcision  is 
placed  too  far  on  the  anterior  surface,  the  capsule  is  not  ex- 
posed through  the  most  convenient  inter-umscular  space,  the 
psoas  muscle  is  not  readily  drawn  aside,  and  the  capsule  must 
be  opened  through  the  iho-femoral  ligament.  The  external 
circumflex  artery  can  scarcely  escape  division. 

In  speaking  therefore  of  excision  of  the  hip  by  an  anterior 
incision  it  wUl  be  considered  that  Mr.  Barker's  operation  is 
implied. 

The  advantages  of  this  operation  are  as  follows : — The 
capsule  is  reached  b}'  a  short  and  direct  route ;  no  muscles  are 
divided  in  exposing  the  joint ;  no  vessels  and  no  neiTes  of  any 


706  OPERATIVE    SURGERY. 

consequence  are  severed ;  the  nutrition  of  the  tissues  around 
the  joint  can  be  but  very  httle  impaired  ;  and  the  least  pos- 
sible amount  of  damage  is  inflicted  upon  the  soft  parts.  The 
neck  of  the  bone  is  divided  in  situ.  The  head  is  not  wrenched 
out  of  the  incision,  a  step  which  not  only  is  apt  to  damage  the 
surrounding  tissues,  but  also  to  strip  off  the  periosteum  be- 
yond the  line  of  section.  The  position  of  the  incision  is  very 
convenient  in  the  after-treatment,  and  permits  of  an  external 
or  a  posterior  splint  being  applied  without  pressure  being 
brought  to  bear  upon  the  wound.  The  Avhole  of  the  diseased 
tissue  is  removed.  All  these  advantages  are  definite  and 
substantial.  One  objection  has  been  urged  against  the 
method.  It  is  said  that  proper  drainage  cannot  be  carried 
out,  and  therefore  healing  must  be  delayed. 

This  objection  Mr.  Barker  has  fully  met  in  his  recent 
communications.  He  has  found  the  anterior  opening  per- 
fectly adequate  for  the  drainage  of  the  cavity  left  by 
the  operation.  Indeed,  in  the  majority  of  the  cases  in 
which  the  whole  of  the  tubercular  disease  has  been  removed 
no  drainage-tube  is  employed,  but  the  wound  is  at  once 
closed.  Out  of  seven  cases  reported  {Brit.  Med.  Journ., 
Nov.  1st,  1890),  no  less  than  six  healed  by  first  intention 
under  one  dressing.  Mr.  Bilton  Pollard  (Med.-Ghir. 
Trans.,  1889)  has  reported  four  cases  of  excision  in  ad- 
vanced hip  disease  with  caseous  abscesses.  The  operation 
was  carried  out  upon  the  lines  laid  down  by  Mr.  Barker. 
The  anterior  incision  was  adopted  in  three  cases,  the  posterior 
in  one.  No  drainage-tubes  were  employed.  The  wounds 
were  dressed  for  the  first  time  on  the  seventh  day,  and  were 
found  to  have  healed  throughout  by  first  intention. 

So  far  as  the  reports  of  cases  of  excision  of  the  hip  afi'ord 
material  for  comparison,  it  is  clear  that  the  operation  above 
described  has  such  advantages  that  it  may  claim  to  be 
considered  the  method  of  election. 

4.  By  a  Posterior  Incision. 

This  operation  differs  but  very  little  from  the  method 
by  an  external  incision  first  described.  The  incision  is 
retro-trochanteric,  commences  opposite  to  the  highest  point 
of  the  acetabulum,  and  is  carried  in  a  curved  direction  along 
the  posterior  part  of  the   trochanter,   maintaining  through- 


EXCISION   OF  HIP.  101 

out  a   distance  of  about  one  inch  from  the   border  of  the 
bone. 

The  ghiteal  muscles  are  cut  through,  the  capsule  is  divided, 
and  the  head  of  the  bone  is  dislocated  and  sawn  oft"  precisely  as 
in  the  operation  first  described. 

The  method  admits  of  excellent  drainage,  but  it  possesses 
the  disadvantages  which  have  been  mentioned  in  connection 
with  the  external  incision,  the  section  of  muscular  tissue  is  con- 
siderable, and  the  wound  is  exposed  to  pressure  during  the 
after-treatment. 

Other    Methods    of    Operating.  —  The    many    methods 
which  have  been  devised  for  the  carrying  out  of  this  opera 
tion  differ  mainly  in  the  situation  of  the  incision. 

Farabeuf  gives  illustrations  of  eighteen  different  methods. 

Retro-trochanteric  incisions  are  common.  An  incision 
advised  by  many  is  that  known  as  the  superior  incision.  It 
follows  the  neck  of  the  femur  above  the  trochanter,  and  then, 
if  an  extension  of  its  length  be  needed,  is  carried  along  the 
posterior  margin  of  that  process.  The  T-shaped  and  the 
horseshoe-shaped  incisions  of  the  earlier  operators  have  not 
survived  the  test  of  time,  and  the  same  may  be  said  of  the 
excisions  carried  out  through  flaps  of  various  sizes  and 
shapes,  which  were  placed,  for  the  most  part,  over  the  great 
trochanter.  Such  flaps  were  executed  by  Lisfranc,  Sedillot. 
Percy,  Roux,  and  others,  but  they  involved  a  quite  unneces- 
sary amount  of  injury  to  the  soft  parts. 

After-treatment. — Dry  dressings  should  be  employed, 
and  if  primary  healing  is  aimed  at,  a  fair  degree  of  pressure 
should  be  brought  to  bear  upon  the  part.  A  dressing  of 
sponges  dusted  with  iodoform,  and  secured  in  position 
by  a  firm  bandage  over  a  layer  of  cotton-wool,  may  be 
recommended.  A  useful  method  of  dressing  is  described  in 
the  account  of  Barker's  operation  (page  705). 

The  limb  must  be  kept  at  perfect  rest,  and  in  the  position 
of  extension.  The  saA\Ti  end  of  the  femur  should  not  be 
allowed  to  remain  in  actual  contact  with  the  acetabulum. 

Of  the  many  splints  advised,  the  most  convenient  are 
either  a  double  Thomas's  splint,  or  a  so-called  box-splint. 
These  splints  are  especially  suited  for  cases  in  which  the 
anterior  incision  has  been  made. 


708  OPERATIVE    SURGERY. 

The  child  is  held  hrmty,  and  can  be  lifted  up  and  turned 
over  "without  any  movement  being  produced  at  the  hip-joint. 
These  cases  require  much  care  in  the  nursing.  The  average 
period  involved  in  the  after-treatment  will  probably  be  not 
much  less  than  six  months  in  any  case  in  which  the  disease 
was  advanced  at  the  time  of  the  operation. 

Results. — The  mortahty  after  excision  of  the  hip  was,  before 
the  days  of  antiseptics,  very  high.  Culbertson  gives  the 
mortality  after  operations  for  disease  as  45*1  per  cent.  The 
mortality  of  the  operation  at  the  present  day  is,  in  properly 
selected  cases,  no  higher  probably  than  5  per  cent.  Mr. 
Wright  has  given  a  list  of  over  one  hundred  cases  of 
excision,  with  only  three  deaths  that  may  be  ascribed  to 
the  actual  operation. 

The  functional  result  after  a  successful  excision  is  usually 
satisfactory.  Anchylosis  very  seldom  follows.  The  limb  is 
frequently  atrophied,  and  some  shortening  is  inevitable.  Sir 
WiUiam  MacCoimac  estimates  that  about  half  of  the  successful 
cases  can  walk  without  the  assistance  of  a  stick,  while  the 
other  half  require  one. 

A  flail-like  condition  of  the  limb,  with,  perhaps,  a  marked 
degree  of  shortening,  will  depend  either  upon  the  removal  of 
an  exceptionally  large  amount  of  bone,  or  upon  allowing  the 
patient  to  move  the  Hmb  and  bear  weight  upon  it  too  early. 

It  must  be  acknowledged  that,  taking  a  large  number  of 
average  cases,  the  results  which  follow  the  treatment  by  rest 
are  superior  in  all  respects  to  such  as  follow  the  treatment  by 
excision. 


709 


CHAPTER    XX. 

Arthrectomy  or  Erasion  of  a  Joint. 

This  operation,  although  it  is  distinct  from  excision,  may 
most  conveniently  be  considered  here. 

It  consists  in  fully  exposing  the  interior  of  the  joint,  and 
in  removing  the  whole  of  the  diseased  synovial  membrane 
and  ligamentous  tissue,  together  with  such  patches  of  cartilage 
or  bone  as  may  be  the  seat  of  quite  limited  disease. 

This  removal  is  accomplished  by  means  of  the  scalpel,  the 
scissors,  the  sharp  spoon,  the  gouge,  and,  if  need  be,  the  actual 
cautery.  The  measure  aims  at  removing  all  the  diseased 
tissue,  and  diseased  tissue  only. 

In  principle  it  represents  the  application  to  the  interior  of 
the  joint  of  a  method  of  dealing  with  certain  morbid  condi- 
tions, known  as  the  method  by  scraping,  which  has  been 
developed  within  the  last  few  years,  and  which  the  introduc- 
tion of  antiseptic  measures  has  allowed  to  be  applied  to  ex- 
tensive and  important  districts. 

The  method  is  in  reality  a  by  no  means  modern  procedure 
revived  and  improved.  The  operation  of  arthrectomy,  as  it 
is  now  known,  would  appear  to  have  been  of  gradual  and 
almost  unconscious  development.  Surgeons  began  cautiously  to 
apply  to  chronically-inflamed  joints,  and,  perhaps,  first  of  all 
to  the  sinuses  about  them,  a  method  of  treatment  they  had 
already  found  successful  in  like  conditions  elsewhere. 

Mr.  Herbert  Page  has  given  a  brief  account  of  the  origin 
of  excision  of  the  knee  and  of  arthrectomy  {Lancet,  Nov.  17, 
1888). 

It  would  appear  that  in  1881  Mr.  Cross,  of  Bristol,  advised 
the  carrjdng  out  of  the  measure  now  known  as  arthrectomy, 
and  he  gave  then  an  illustrative  case. 

Since  that  time  the  procedure  has  rapidly  developed. 

To  Mr.  G.  A.  Wright  is  due  the  credit  of  beine  amonsr  the 


TiO  OPERATIVE    SUBGEBY. 

first  to  publish  any  detailed  account  of  the  procedure.  He 
has,  moreover,  done  much  to  elaborate  and  perfect  the  opera- 
tion, to  give  it  a  definite  position  among  surgical  methods, 
and  to  establish  its  value  and  its  application  as  a  mode  of 
treatment. 

His  first  case  was  published  in  the  Lancet  for  1881.  A 
fuller  communication  was  made  before  the  British  Medical 
Association  in  1883,  and  in  1885  a  series  of  sixteen  cases  was 
published  in  the  Medical  Chronicle. 

The  operation  is  chiefly,  if  not  entirely,  applicable  to  the 
knee-joint.  It  has  been  carried  out  in  the  elbow  and  ankle, 
but,  as  Mr.  Wright  observes  {Lancet,  1888),  "  in  joints  with 
complex  bony  surfaces,  and  in  joints  where  free  mobility  is  an 
important  element,  also  in  joints  where  the  primary  and  main 
lesion  is  bony,  the  operation  can  never  have  any  great  measure 
of  success." 

Briins'  method  of  performing  arthrectomy  of  the  ankle  is 
described  at  the  end  of  this  chapter. 

Arthrectomy  forms  an  essential  part  of  all  excisions  for 
chronic  joint-disease,  it  being  necessary  that  all  traces  of 
tubercular  tissue  should  be  removed  by  scraping  or  dissection 
after  the  articular  parts  of  the  bones  have  been  sawn  off. 

The  measure  may  be  regarded  as  a  conservative  one,  and 
is  applicable  to  relatively  early  cases.  It  is  distinctly  un- 
suited  for  examples  of  advanced  disease,  except  as  an  accessory 
measure.  It  is  not  adapted  for  cases  attended  by  much  sup- 
j)uration.     It  is  especially  applicable  to  children. 

Instruments  Required. — Excision  knife ;  scalpels ;  scissors, 
both  straight  and  curved  on  the  flat ;  sharp  spoons  of  various 
sizes  and  sha]  )es ;  gouges  ;  toothed  forceps ;  dissecting  and 
artery  forceps  ;  pressure  forceps ;  probe ;  retractors. 

The  Operation  {as  applied  to  the  knee-joint). — An  Esmarch's 
band  is  not  required,  nor  is  any  form  of  tourniquet  needed. 

The  patient  lies  upon  the  back,  with  the  knee  a  little 
flexed,  and  the  sole  of  the  foot  resting  flat  upon  the  table. 

The  surgeon  stands  to  the  outer  side  of  the  limb,  or  he 
may  find  it  convenient  to  place  himself  upon  the  right  side  in 
the  case  of  either  limb.     An  assistant  placed  at  the  end  of  the 


ABTHRECTOMY.  711 

table,  and  another  opposite  to  the  surgeon,  hold  the  limb 
securely.  A  third  helper  by  the  surgeon's  side  attends  to  the 
sponging,  etc. 

A  curved  transverse  incision  is  made  across  the  front  of 
the  knee-joint,  as  in  performing  excision  (page  684).  The 
incision  may  be  commenced  at  the  posterior  part  of  one  con- 
dyle of  the  femur,  be  carried  across  the  front  of  the  limb 
over  the  middle  of  the  patellar  ligament,  and  end  at  the 
posterior  part  of  the  other  condyle. 

The  patellar  ligament  is  divided,  the  joint  fully  opened, 
and  the  skin  flap  with  the  patella  turned  up  upon  the  thigh. 

The  knee  is  now  flexed  at  a  right  angle,  and  the  interior  of 
the  joint  well  exposed. 

The  surgeon  then  proceeds  to  remove  all  the  diseased 
synovial  membrane,  and  such  of  the  extra-synovial  tissue  as 
is  also  involved.  The  latter  would  mclude  all  softened  liga- 
mentous tissue.  As  much  as  possible  should  be  removed  in  a 
continuous  layer  by  means  of  the  scalpel  and  forceps,  or  the 
scissors  and  forceps.  The  semilunar  cartilages  are  removed, 
and  probably  both  lateral  ligaments. 

The  crucial  ligaments  should  be  spared  whenever  possible. 
They  must  be  stripped,  however,  of  every  trace  of  diseased 
membrane,  must  be  most  carefully  inspected,  and  subjected 
to  a  vigorous  scraping  over  all  suspicious  parts. 

The  articular  surface  of  the  posterior  ligament  must  be 
exposed,  and  also  freed  of  all  degenerate  and  pulp}^  tissue. 

This  ligament  should  not  be  divided,  nor  should  any  open- 
ing, if  possible,  be  made  into  the  popliteal  space. 

When  the  mter-articular  district  has  been  completed,  and 
the  Avork  of  the  scalpel  or  scissors  followed  up  by  the  sharp 
spoon,  until  no  trace  of  disease  has  been  left  behind,  the 
surgeon  turns  to  the  anterior  flap. 

All  the  synovial  membrane  which  covers  this  fla23  should 
be  dissected  off",  the  subcrural  bursa  must  be  fully  opened  up, 
and  its  lining  membrane  treated  in  the  same  way.  Every 
nook  and  cranny  must  be  patiently  explored,  and  every 
fragment  of  tubercular  tissue  removed.  The  complete  re- 
moval of  every  scrap  of  diseased  tissue  from  the  subcrural 
bursa  is  very  important. 

Here  again,  also,  the  erasion  must  be  completed  with  the 


712  OPERATIVE    SUBGEBY. 

sharp  spoon,  and  every  neglected  point  and  corner  subjected 
to  a  careful  and  complete  scraping. 

Finally,  the  cartilages  and  bones  must  be  well  examined. 
Patches  of  softened  or  eroded  cartilage  may  be  sliced  off,  and 
points  of  caries  in  the  bones  freely  removed  with  the  gouge. 

The  bleeding  is  arrested  by  the  pressure  of  a  sponge, 
which  is  maintained  as  long  as  possible,  and  by  means  of 
pressure  forceps.     Ligatures  are  but  seldom  required. 

The  articulation  is  then  well  washed  out  with  some  anti- 
septic solution  (e.g.,  carbolic  solution,  1  in  40),  well  sponged, 
and  dried. 

The  Hmb  is  placed  upon  the  splint  prepared  for  it,  and  the 
patellar  Hgament  having  been  united  by  many  points  of 
chromicised  catgut  the  wound  is  closed  with  sOkworm  gut. 

Drainage-tubes  should  be  avoided  whenever  possible,  and 
in  a  large  percentage  of  the  cases  they  can  be  dispensed  with, 
provided  that  the  margins  of  the  wound  are  not  too  closely 
approximated. 

If  drains  be  considered  necessary,  one  should  be  inserted 
into  the  posterior  angle  of  the  wound  on  each  side. 

The  tubes  should  be  removed  within  forty-eight  hours. 
The  best  dressing  is  formed  of  sponges  dusted  with  iodoform. 
A  layer  of  cotton-wool  and  gauze  may  cover  the  sponges,  and 
then  the  whole  dressing  is  secured  with  a  tightly-drawn  flannel 
bandage,  so  that  good  pressure  may  be  brought  to  bear  upon 
the  part. 

Mr.  Barker's  method  of  removing  diseased  tissue  in  chronic 
joint  affections  by  means  of  his  flushing-gouge  is  described  in 
connection  with  excision  of  the  hip  (page  704). 

The  Operation  (as  applied  to  the  ankle). — The  method  of 
Briins  is  the  best,  and  is  described  in  the  Munchener  Med. 
Wochenschrift  No.  24,  1891. 

Two  vertical  incisions  are  made  in  front  of  the  ankle,  each 
commencing  about  4  cm.  above  the  line  of  the  joint  and 
carried  down  in  front  of  the  corresponding  malleolus  to  the 
level  of  the  medio-tarsal  joint.  Through  these  incisions  the 
anterior  part  of  the  ankle  joint  "is  dealt  with. 

Two  posterior  vertical  incisions  arc  then  made,  one  on 
each  side  of  the  tendo  Achillis,  and  through  these  the  hinder 
part  of  the  articulation  is  treated. 


ABTHBEGTOMY.  713 

Comment. — The  removal  of  the  diseased  tissue  must  be 
precise  and  complete.  The  operator  must  be  able  to  recognise 
healthy  tissue  from  that  implicated  by  the  disease,  and 
success  is  never  encouraged  by  violent  and  indiscriminate 
scraping. 

In  gouging  bone  it  must  be  remembered  that  all  softened 
bone  is  not  necessarily  carious,  and  that  simply  because  a 
district  of  cancellous  bone  yields  to  the  gouge  it  must  not  be 
assumed  that  it  is  hopelessly  diseased. 

The  use  of  the  actual  cautery  should  be  avoided.  It  inter- 
feres with  primary  healing. 

It  is  important  that  the  crucial  ligaments  be  preserved. 

The  practice  of  making  a  hole  through  the  posterior 
ligament,  and  of  introducing  a  drainage-tube  which  traverses 
the  popliteal  space  and  escapes  by  the  skin  of  the  ham,  is  to 
be  condemned. 

If  the  wound  be  carried  far  enough  back,  drainage  by  two 
lateral  tubes  will  be  found  to  be  ample. 

After-treatment.  —  This  closely  follows  the  treatment 
observed  after  excision  of  the  knee. 

The  limb  should  be  supported  by  a  back  splint,  which  ex- 
tends from  the  fold  of  the  nates  to  beyond  the  heel,  and 
terminates  in  a  rectangular  foot-piece. 

Such  an  apparatus  may  be  supplemented  by  a  side  splint 
if  needed.     The  limb  should  be  raised. 

Dry  and  infrequent  dressings  are  to  be  recommended. 

As  soon  as  the  wound  has  soundly  healed,  a  Thomas's  splint 
may  be  applied,  and  the  patient  be  allowed  to  go  about  with 
the  aid  of  crutches  and  a  patten. 

A  rigid  apparatus  must  be  kept  applied  to  the  limb  for  a 
considerable  time  after  all  appears  sound  and  well  "  As  in 
excision,  flexion  wiU  occur  unless  the  limb  is  kept  fixed  for 
from  two  to  three  years  at  least."  Thus  writes  Mr.  Wright 
m  1888. 

Results. — "  The  results,"  savs  Mr.  Wright,  "  in  successful 
cases  are  better  than  those  of  excision,  in  that  there  is  no 
shortening  whatever,  either  immediate  or  as  growth  goes  on, 
while  the  results  in  other  respects  are  like  those  of  excision, 
for  a  ftrm,  stiff,  straight  limb  is  obtained.     Mobility,  though 


714  OPERATIVE    SURGE  BY. 

possible,  is  not  to  be  counted  upon.  .  .  .  Cases  of  both 
evasion  and  excision  require  long  watching,  to  prevent  dis- 
tortion, and  there  is  httle  difference  between  the  two  in  this 
respect." 

The  recovery  is  on  the  whole  quicker,  less  painful,  and 
less  troublesome. 

The  risk  to  hfe  involved  b}^  the  operation  is  very  small 
indeed.  Testimon}^  to  the  admirable  results  obtained  by  this 
operation  has  now  been  afforded  by  many  surgeons,  and  its 
position  may  be  considered  to  be  firmly  established. 


715 


CHAPTER    XXI. 

Excision  of  the  Upper  Jaw. 

This  operation  is  considered  to  refer  usually  to  the  removal 
of  the  superior  maxillary  bone  of  one  side,  but  to  include  also 
the  rarer  operation  in  which  both  bones — and  therefore  the 
whole  of  the  upper  jaw — are  excised  at  one  sitting. 

The  operation  has  been  performed  for  the  relief  of  several 
conditions,  but  is  at  the  present  day  almost  limited  to  the 
treatment  of  malignant  growths  (epithelioma  and  sarcoma) 
which  involve  the  upper  maxilla. 

The  operations  for  the  removal  of  innocent  tumours  are 
for  the  most  part  partial,  and,  indeed,  the  conditions  must  be 
very  exceptional  in  which  the  excision  of  the  entire  bone  on 
one  side  would  be  called  for  in  dealing  with  an  innocent 
growth. 

Partial  excisions,  and  the  so-called  osteo-plastic  or  tem- 
porary excision,  are  dealt  with  on  page  725  et  seq.,  and  in  the 
subsequent  chapter  (page  729). 

The  value  of  the  usual  operation — viz.,  the  removal  of  one 
superior  maxilla  for  malignant  disease — is  a  matter  of  question. 
Mr.  Butlin  is  of  opinion  that,  "  unless  there  is  a  reasonable 
hope  that  better  results  will  be  procured  in  future,  the 
operation  must  be  condemned."  The  subject  is  further 
alluded  to  in  the  section  on  "  Results." 

The  operation  was  originally  proposed  by  Lizars  in  1826 
("A  System  of  Anatom.  Plates,"  part  ix.,  Edin.,  1826),  but 
was  first  carried  out  (independently  of  Lizars'  suggestion)  by 
Oensoul  in  1827  (Lettre  Chirurgicale,  etc.,  Paris,  1833). 

On  many  occasions  previous  to  these  dates  portions  of  the 
upper  jaw  had  been  removed,  or  the  contents  of  the  antrum 
evacuated.  The  excision  of  both  superior  maxillary  bones  at 
one  sitting  appears  to  have  been  tirst  accomplished  by 
Heyfelder  in  1844. 


716  OPERATIVE    SURGERY. 

Anatomical  Points, — The  details  of  the  anatomy  of  the 
superior  maxillary  bone  must  be  borne  in  mind  as  well  as  its 
relations  to  surrounding  parts.  The  bone  forms  the  largest 
part  of  the  face,  of  the  outer  wall  of  the  nose,  of  the  roof  of  the 
mouth,  and  of  the  floor  of  the  orbit.  The  bone  as  a  whole  is 
thin  and  shell-lil?:e,  its  most  substantial  part  being  the  malar 
process.  It  articulates  with  nine  bones,  and  no  less  than  nine 
muscles  are  attached  to  it. 

The  bony  connections  to  be  dealt  with  in  the  operation  are 
the  following: — (1)  The  connection  with  the  malar  bone  at 
the  outer  side  of  the  orbit ;  (2)  the  connection  of  the  nasal 
process  with  the  frontal,  nasal,  and  lachrymal  bones ;  (3)  the 
connections  of  the  orbital  plate  with  the  ethmoid  and  palate ; 
(4)  the  connection  with  the  opposite  bone,  and  with  the 
palate  in  the  roof  of  the  mouth ;  and  (5)  the  connection 
behind  with  the  palate  bone  and  the  fibrous  attachments  to 
the  pterygoid  processes. 

In  excising  the  bone  in  the  Hving  subject,  the  upper  part 
of  the  nasal  process  is  usually  left  behind,  the  malar  bone  is 
divided,  and  a  portion  of  it  removed  with  the  maxilla.  The 
inferior  turbinated  bone  is  of  course  included  in  the  parts 
excised,  and  also  the  whole  or  the  greater  part  of  the  palate 
bone. 

In  cutting  through  the  nasal  process  the  lachrymal  sac 
will  be  damaged,  and  the  nasal  duct  cut  across. 

The  attachments  of  the  soft  palate  to  the  palate  bone 
must  be  severed. 

The  blood-vessels  which  are  concerned  in  the  operation  are 
certain  branches  of  the  facial  artery,  the  infraorbital  artery, 
the  alveolar  branch  of  the  internal  maxillary,  the  descending 
palatine,  pterygo-palatine,  and  spheno-palatine  arteries,  and  the 
deep  facial  vein. 

All  these  vessels  are,  under  normal  conditions,  small. 

Instruments  Required: — Gag;  tracheotomy  tube;  scalpels; 
tooth  force2)S  ;  bone-cutting  forceps  of  various  patterns  ; 
sequestriim  forceps  ;  lion  forceps  ;  volsella  ;  metacarpal  saw  ; 
chisel  and  mallet ;  rugine  ;  periosteal  elevator  ;  strong  scissors, 
both  straight  and  curved  on  the  flat ;  dissecting,  artery,  and 
pressure  forceps ;  Paquelin's  cautery  ;  harelip  pins,  needles, 
sutures,  etc. ;  sponge-holders. 


EXCISION    OF    UPPER   JAW.  Ill 

Preliminary  Measures. — During  tlie  performance  of 
the  operation  considerable  danger  may  be  incurred  from 
heemorrhage.  Not  only  may  the  bleeding  be  copious  in 
amount,  but  the  blood  may  readily  find  its  way  into  the  air- 
passages. 

Various  measures  have  been  adopted  to  meet  this  com- 
plication. Lizars  in  his  first  operation  ligatured  the  internal 
maxillary  and  temporal  arteries  as  a  prehminary  step.  In 
his  second  case  he  secured  the  external  carotid.  With  a 
like  object  in  view,  a  ligature  of  the  common  carotid  has  been 
both  advised  and  carried  out. 

Professor  Rose  advises  that  the  head  be  so  far  thrown  back 
that  the  vertex  looks  towards  the  ground,  and  points  out  that 
in  that  attitude  the  blood  can  only  occupy  the  upper  part  of 
the  pharynx,  and  must  escape  through  the  wound  and  the 
nose. 

The  position,  however,  is  most  inconvenient  to  the  surgeon, 
it  does  not  prove  so  efficacious  as  it  may  appear,  and  it  leads 
to  considerable  venous  congestion  of  the  head  and  face. 

Some  operators  make  a  practice  of  performing  tracheotomy, 
and  of  then  plugging  the  larynx  with  a  piece  of  fine  Turkey 
sponge  to  which  a  tape  is  attached  ;  or  they  make  use  of 
Trendelenburg's  tracheal  tampon-cannula. 

In  connection  with  this  matter  I  would  say  that  the 
preliminary  ligature  of  a  main  artery  is  not  a  necessary  or 
desirable  proceeding.  Should,  however,  the  tumour  be 
exceedingly  vascular,  e.g.,  suppose  it  to  be  an  extensive 
angeioma,  a  temporary  loop  may  be  placed  around  the 
external  carotid  artery.  This  loop  could  be  drawn  upon 
during  the  operation,  and  removed  when  the  bleeding  had 
been  dealt  with. 

I  have  used  Trendelenburg's  cannula  in  many  operations 
within  the  mouth,  and  have  found  it  always  to  effect  its 
purpose.  Care  should  be  taken  to  test  the  instrument  before 
it  is  employed.  The  thin  india-rubber  tissue  which  forms  the 
tampon  soon  perishes,  and  should  be  replaced  every  time  the 
instrument  is  used.  Even  if  this  cannula  be  employed,  it  is 
necessary  to  place  a  sponge  over  the  larynx,  as  a  considerable 
clot  may  form  in  the  lar^Tigeal  cavit}?^  above  the  tampon.  It 
may  be  here  observed  that  if  the   cannula   be  retained  for 


71S  OPERATIVE    SUBGEBY. 

some  time  after  the  operation,  as  a  precaution  in  the  event 
of  secondary  bleeding  occurring,  it  will  probably  be  found  to 
be  no  longer  of  effect  in  plugging  the  trachea.  If  the  instru- 
ment be  retained,  the  india-rubber  tissue  is  very  apt  to 
become  disors^anised ;  and  in  the  case  of  one  cannula  which 
had  been  retained  only  forty-eight  hours  I  found  the  tampon 
on  removal  to  be  represented  only  by  mere  shreds  of  india- 
rubber. 

The  question  of  a  suitable  tampon-cannula,  and  the  use  of 
Hahn's  caimula,  will  be  found  discussed  in  the  section  on  the 
"  plugging  of  the  trachea  "  as  a  preliminary  to  excision  of  the 
larjmx  (vol.  ii.,  page  151). 

In  the  majority  of  cases,  neither  the  preliminary  ligature 
of  an  artery,  nor  a  preliminary  tracheotomy  is  necessary. 

If,  on  the  other  hand,  the  posterior  nares  be  carefully 
plugged  before  the  operation,  if  the  division  of  the  palate  be 
left  to  the  last,  if  the  latter  stages  of  the  operation  be  rapidly 
executed,  and  if  an  assistant  is  very  ready  with  pressure 
forceps  and  sponges,  it  will  usually  be«  found  that  the  bleed- 
ing can  be  efficiently  dealt  with. 

It  is  needless  to  point  out  that  a  tracheotomy,  or  a  wound 
to  expose  the  carotid  artery,  adds  another  danger  to  a  pro- 
ceeding already  formidable  enough. 

COMPLETE   OPERATIONS. 

The  many  different  methods  described  for  excising  this 
bone  are  distinguished  from  one  another  by  little  else  than 
the  disposition  of  the  skin  incision. 

The  following  operations  will  be  described.  The  first 
represents  what  may  be  conveniently  called  the  median 
incision,  the  second  represents  the  cheek  incision,  and  the 
third  the  method  of  exposing  the  jaw  through  a  flap : — 

1.  The  operation  by  a  median  incision. 

2.  Velpcau's  operation. 

3.  Langenbeck's  operation. 
4  Other  methods. 

1.  The  Operation  by  a  Median  Incision. 
This  procedure  forms  without  doubt  the  best  measure  for 
excising  the  superior  maxilla. 

The  operation   is  known   in   most   French  text-books  a& 


EXCISION    OF    UPPER    JAW.  719 

Nelaton's  or  Listen's  operation,  and  in  most  English  books  as 
Fergusson's  operation. 

The  exact  methods  carried  out  by  Liston  and  Fergusson 
are  alluded  to  in  a  later  section.  The  present  operation  would 
apjDcar  to  have  originated  with  Blandin  ("  Anat.  Topograph.," 
1834,  page  122). 

The  patient  lies  upon  the  back,  with  the  head  and 
shoulders  well  raised.  The  face,  if  the  patient  be  a  male, 
should  have  been  already  shaved.  The  head  is  turned  to  the 
sound  side. 

The  surgeon  stands  on  the  patient's  right-hand  side  in 
dealing  with  either  side  of  the  jaw.  The  chief  assistant 
should  take  his  place  opjoosite  to  him.  Another  assistant 
may  stand  by  the  surgeon's  side.  The  posterior  nares  are 
well  plugged. 

1.  The  incision  is  commenced  at  a  point  half  an  inch 
below  the  inner  canthus,  is  carried  down  by  the  side  of  the 
nose — where  the  nose  joins  the  face — follows  the  groove  which 
hmits  the  ala  nasi,  and,  skirting  the  nostril,  reaches  the  median 
line  of  the  lip. 

While  this  cut  is  being  made,  an  assistant  may  compress 
the  facial  artery. 

When  the  hp  is  reached,  the  chief  assistant  grasps  each 
extremity  of  the  lip  (at  either  angle  of  the  mouth)  between 
the  finger  and  thumb,  so  as  to  compress  the  coronary  arteries. 
The  incision  is  then  carried  through  the  median  line  of  the 
upper  lip  into  the  mouth  (Fig.  218,  a). 

The  superior  coronary  arteries  are  at  once  seized  and 
secured. 

While  dealing  with  the  lip  the  upper  part  of  the  wound  is 
being  compressed  by  a  sponge. 

In  this  stage  of  the  operation  the  following  vessels  are 
divided : — The  angidar  artery  and  the  large  angular  vein,  the 
lateralis  nasi  artery,  the  superior  coronary,  the  artery  to  the 
nasal  septum,  and  some  trifling  branches  of  the  infraorbital 

2.  A  second  incision  is  now  carried  along  the  lower 
margin  of  the  orbit.  At  its  commencement  it  starts  from  the 
point  of  the  first  incision,  and  ends  over  the  malar  bone 
(Fig.  213,  a). 

3.  The  cheek  flap  thus  marked  out  is  now  rapidly  raised 


720  OPERATIVE    SURGERY. 

from  the  bone,  and  should  contam  all  the  soft  parts  down  to 
the  maxilla.  No  attempt  should  be  made  to  save  the 
periosteum.  In  dissecting  up  this  flap  the  infraorbital  artery 
is  divided.  Care  should  be  laken  that  no  blood  runs  into  the 
mouth,  and  an  assistant  should  follow  the  flap  with  a  sponge. 

Throughout  the  operation  sponge  pressure  is  the  main 
means  of  checking  haemorrhage. 

4.  The  operator  should  now  separate  the  nasal  cartilages 
from  the  bone,  and  should  then  divide  the  nasal  process. 
This  may  be  done  with  a  fine  saw  or  a  chisel  (Fig.  215,  a). 
He  should  next  proceed  to  divide  the  periosteum  along  the 
lower  edge  of  the  orbit.  With  the  elevator  the  periosteum  of 
the  floor  of  the  orbit  is  carefully  raised,  and  in  effecting  this 
the  origin  of  the  inferior  oblique  muscle  is  separated. 

With  a  fine  chisel  the  orbital  plate  may  be  divided  as  far 
within  the  orbit  as  is  necessary.  The  chisel-cut  will  com- 
mence at  the  point  at  which  the  nasal  process  of  the  maxilla 
has  been  divided,  and  will  end  at  the  spheno-maxillary  fissure 
(Fig.  215).  If  it  be  considered  necessary  to  take  away  the 
whole  of  the  orbital  plate  of  the  maxilla,  then  a  chisel-cut 
can  scarcely  avail,  and  the  bone  must  be  wrenched  away  from 
its  attachments  in  the  final  act  of  removal. 

The  last  step  of  this  stage  of  the  operation  is  to  divide  the 
malar  bone.  This  may  be  done  with  a  chisel  or  a  small 
saw.  The  malar  bone  is  divided  obliquely  (from  above  down- 
wards and  outwards)  at  a  point  about  the  centre  of  the  bone, 
and  the  saw  or  chisel  is  so  applied  that  the  section  will  extend 
into  the  spheno-maxillary  fissure,  the  exact  site  of  which 
should  have  been  previously  defined  (Fig.  215,  b). 

5.  The  palate  part  of  the  bone  alone  remains  with  its 
connections  undisturbed.  The  mouth  having  been  well 
opened,  the  central  incisor  tooth  on  the  diseased  side  is  re- 
moved, the  muco-periosteal  covering  of  the  hard  palate  is 
divided  in  the  median  line,  and  a  knife  is  drawn  along  the 
floor  of  the  nose  from  before  backwards,  and  as  near  as 
possible  to  the  septum.  By  means  of  a  transverse  incision 
made  through  the  mouth,  the  soft  palate  is  loosely  separated 
from  the  hard. 

A  key-hole  saw  is  now  introduced  through  the  nose,  and 
the   bony  palate  divided   as   near  to  the  median  line  as   is 


EXCISION    OF    UPPER    JAW. 


7-21 


possible  (Fig.  215,  c).  This  step  of  the  operation  should  be 
rapidly  performed,  as  there  is  often  much  bleeding  from  the 
palatine  arteries,  which  are  necessarily  divided. 

6.  The  surgeon  finally  grasps  the  bone  with  lion  forceps, 
holding  the  instrument  with  its  blades  opened  vertically. 
One  blade  takes  hold  of  the  orbital  plate,  and  the  other  of  the 
alveolus.  The  maxilla  is  then  wrenched  from  its  few  remain- 
ing attachments.  These  will,  in  part,  concern  the  orbital  plate, 
and  in  part  the  attachment  existing  between  the  maxilla 
and  the  pter3'goid  process.  The  separation  of  the  bone  ft'om 
the  last-named  process  may 
be  aided  by  bone-cutting 
forceps  bent  at  an  angle, 
and  introduced  behind  the 
maxillary  tuberosity. 

Care  must  be  taken  at 
•this  stage  that  the  soft 
palate  is  freed  completely 
from  its  connections  with 
the  hard. 

Without  bringing  much 
force  to  bear  upon  the  for- 
<;eps  the  bone  is  finally 
removed. 

7.  Any  bleeding  from 
the  depths  of  the  cavity 
should  now  be  checked  so 
far  as  is  possible. 

It  will  usually  be  desir- 
able to  plug  the  cavity 
with  gauze.  Carbolised 
iodoform,  or  alembroth 
gauze  ma}'  be  employed.  The  amount  introduced  must  be 
noted,  and  the  ends  of  the  strips  so  placed  that  they  can  be 
readily  reached  from  the  mouth. 

A  silk  thread  may  be  attached  to  the  end  of  each  strip, 
and  brought  out  of  the  mouth  and  fastened  to  the  cheek. 

The  actual  cauter}'^  may  sometimes  be   used   Avith   good 
effect  to  check  the  haemorrhage. 

The   skin   wound   is   finally   united    very   carefully   with 

U   II 


Fig.    213. — EXCISION   OF   THE   UPPEE  JAW. 

,   By  a  median  incision  ;   B,  By  Velpeau"s 
method  ;  C,  Excision  of  the  lower  jaw. 


7-22  OPERATIVE    SUEGEBY. 

silkworm-gut  sutures,  especial  care  being  taken  to  accu- 
rately adjust  the  red  margin  of  the  lip.  Xo  harelip  pins  are 
necessary  in  any  ordinary  case. 

The  Avound  is  finally  well  dusted  with  iodoform,  and 
dressed  with  a  sponge  held  in  place  by  a  flannel  bandage. 

Comment. — This  operation  has  the  following  great  advan- 
tages:— The  bone  is  well  exposed,  and  plenty  of  room  is  pro- 
vided for  its  excision,  the  vessels  and  nerves  are  cut  at  a 
distance  from  their  trunks,  the  salivary  duct  is  not  interfered 
with,  and  the  scar  is  so  placed  as  to  produce  but  little 
deformity.  The  operation,  moreover,  allows  of  easy  control 
of  the  hemorrhage. 

In  the  matter  of  the  resulting  deformity  Mr.  Butlin 
observes  ("  Op?rative  Surgery  of  Malignant  Disease,"  1887, 
page  128) : — "  When  the  lower  margin  of  the  orbit  has  been 
removed,  the  lower  eyelid  often  swells,  becomes  red  and 
(edematous,  and  mav  remain  so  in  spite  of  every  means  taken 
to  relieve  it.  The  distiguremer.^  produced  by  this  cause  is 
very  marked." 

If  the  posterior  nares  be  plugged,  and  if  the  steps  of  the 
operation  be  followed  in  the  order  given,  no  blood  should  tind 
its  Avay  into  the  mouth  until  the  last  stages  of  the  excision  are 
reached.  Farabeuf  does  not  divide  the  lip  until  towards  the 
last.  His  tirst  incision  ends  at  the  ala  of  the  nostril  The 
nasal,  orbital,  and  malar  parts  of  the  bone  are  separated. 
The  cut  is  finally  carried  through  the  lip,  and  the  palate 
segment  of  the  bone  dealt  with. 

In  many  text-books  the  removal  of  the  incisor  tooth  is 
one  of  the  first  steps  of  the  operation.  This  is  not  necessary, 
and  blood  from  the  socket  ot  the  tooth,  running  into  the 
mouth,  may  add  a  needless  complication  to  the  procedure. 

The  excision  should  be  carried  out  rapidly,  but  without 
haste,  and  above  all  without  violence. 

The  connections  of  the  bone  must  be  Avell  freed  before  an 
attempt  should  be  made  to  ^sTench  it  away. 

Carefully-applied  pressure  with  fine  Turkey  sponge  affords 
the  best  means  throughout  the  operation  of  dealing  with 
haemorrhage. 

It  is  useless  to  make  any  attempt  to  save  the  muco- 
periosteal  covering  of  the  hard  palate. 


EXCISION    OF    UPPER   JAW.  7-2:^ 

French  surgeons  nsnally  employ  a  chain-saw  to  divide  the 
malar  bone.  The  saw  is  conducted  into  position  by  means  of 
a  curved  needle,  which  is  passed  through  the  sphen(vniaxillary 
fissure. 

It  not  inft-equently  happens  that  the  bone  breaks  up 
during  removal,  and  has  then  to  be  taken  away  in  fragments. 

After  the  removal  of  the  maxilla  the  cavity  should  be  ex- 
amined for  any  traces  of  the  growth.  It  is  apt  to  spread  to 
the  pterygoid  plates,  which  need  very  careful  inspection. 

2.  Velpeau's  Operation. 

In  this  operation  the  incision  is  commenced  at  the  angle 
of  the  mouth,  and  is  can-ied,  in  a  curved  direction,  through 
the  cheek  to  end  over  the  centre  of  the  malar  bone  (Fig.  213,  r>). 
The  incision  is  carried  directly  into  the  mouth,  and  the  flap 
thus  formed  is  turned  inwards. 

The  operation  is  completed  precisely  in  the  manner  already 
described. 

Commevf. — This  incision  is  a  modification  of  that  originally 
proposed  b}'^  Lizars. 

Compared  with  the  previous  operation  it  has  these  dis- 
advantages : — The  bone  is  not  so  readily  exposed,  and  there  is 
greater  difficulty  in  dealing  with  its  orbital  and  nasal  portions. 
The  arteries  of  the  face  are  divided  nearer  to  the  trunk.  The 
parotid  duct  is  wounded.     An  ugly  scar  results. 

The  measure,  however,  is  of  value  in  cases  in  which  the 
cheek  is  to  a  small  extent  invaded,  and  in  which  it  is  possible 
that  the  involved  skin  can  be  removed  by  widening  the  cut 
at  the  necessar}-  spot. 

The  question,  however,  would  remain  as  to  whether  an 
operation  would  be  justifiable  in  such  a  case. 

This  procedure  was  followed  by  Warren,  BallingaU,  and 
others,  and  is  still  advised  by  Oilier. 

3.  Langenbeck's  Operation. 

In  this  method  the  skin  incision  commences  at  the  side 
of  the  nose,  at  the  junction  of  the  nasal  cartilage  with  the 
nasal  bone.  It  then  passes  with  a  downward  convexity  to  the 
junction  of  the  upper  lip  with  the  cheek,  and  is  finally  carried 
upwards  and  outwards  to  end  over  the  middle  of  the  malar 
bone.    In  this  way  a  large  U-shaped  flap  is  formed  (Fig.  214..  a) 


724 


OPERATIVE    SURGERY. 


The  incision  is  carried  down  to  the  bone,  and  the  flap  reflected 
upwards  and  outwards.  The  operation  is  completed  in  the 
manner  ah'eady  described. 

Comment. — But  a  comparatively  small  space  is  afforded 
b}^  this  method,  and  while  the  procedure  is  not  ill-adapted  for 

some  partial  operations,  it 
is  not  convenient  when 
the  whole  bone  has  to  be 
removed. 

The  duct  of  the  paro- 
tid gland  is  cut,  and  many 
branches  of  the  facial 
nerve  are  divided. 

The  resulting  scar  is 
very  unsightly. 

The  advantages  claim- 
ed for  the  method  are  the 
following  : — The  lip  is  not 
divided,  and  therefore  the 
form  of  the  mouth  is  pre- 
served. The  incision  ma}' 
be  so  placed  that  the 
trunk  of  the  facial  artery 
is  avoided. 

4.  Other  Methods. 
Liston  made  use  of 
three  incisions.  (1)  A  cut 
from  the  external  angular  process  of  the  frontal  bone  through 
the  cheek  to  the  angle  of  the  mouth.  (2)  A  short  incision  along 
the  zygoma  to  meet  the  first  incision.  (3)  A  cut  along  the  side 
of  the  nose  and  through  the  centre  of  the  lip  (Lancet,  March, 
1836  ;  and  "Practical  Surgery,"  2nd  ed.,  1838,  page  279). 

Fergusson  made  the  same  naso-labial  incision  as  Liston, 
carrying  the  cut  up  to  within  half  an  inch  of  the  inner 
canthus.  He  made  a  second  incision  from  the  angle  of  the 
mouth  to  the  malar  bone,  and,  if  needed,  a  third  incision  at 
right  angles  to  the  outer  extremity  of  the  buccal  Avound 
(Lancet,  March,  1842  ;  and  "  Practical  Surgery,"  2nd  ed.,  1846, 
page  .5.50). 

GenaouUs  incisions   were    remarkable.      One  was   carried 


Fig.    214. — EXCISION   OF  THE   TJPPEE  JAW. 

A,  By  Langenbeck's  method  ;  B,  By  Gensoul's 
method. 


EXCISION    OF    UPPER    JAW. 


725 


vertically  downwards  from  the  level  of  the  inner  canthus  to 
divide  the  lip  opposite  to  the  bicuspid  tooth ;  a  second  cut 
started  at  right  angles  to  the  first  at  the  level  of  the  floor  of 
the  nose ;  and  a  third  was  carried  upwards  in  front  of  the 
ear  to  the  external  angular  process  of  the  frontal  bono 
(Fig.  214,  15). 

Comment. — These  methods  are  enumerated  in  order  to 
make  clear  the  precise  operations  adopted  by  surgeons  who^ie 
names  are  some- 
what loosely  em- 
ployed in  connec- 
tion with  excision 
of  the  jaAv. 

Gensoul  was 
the  first  surgeon 
to  remove  the 
superior  maxilla. 

These  histori- 
cal operations 
have  all  been  re- 
placed by  more 
practical  meas- 
ures. 

PARTIAL  OPERA- 
TIONS. 

1.  The  alveolar 
part  of  the  bone 
and  the  palate 
process     may     be 


readily 

through 

mouth 


removed 

the 

without 


SAW   INCISIONS   IN   THE   MAXILtS. 


A,  B,  c,  Excision  of  upper  jaw  ;  d,  Koeckel's  operation 
(nasal  ])olypiis)  ;  e,  c,  Guerin's  oper:ition  (partial  ex- 
cision) ;  r,  K,  Langenbeck's  operation  (nasal  polypus) ; 
G,  Excision  of  lower  jaw  ;  H,  Removal  of  portion  of 
alveolus  ;  I,  Esniarch's  operation  (anchylosis  of  jaw). 


making  any  inci- 
sion in  the  skin. 
The  upper  lip  is 
everted,  and  is  either  held  up  by  suitable  forceps  or  drawn  up 
by  retractors.  The  tissues  of  the  cheek  can,  if  needed,  be 
separated  to  the  required  extent  from  the  bone  by  dividing  the 
mucous  membrane  alony:  the  line  at  which  it  is  refiocted  froiij 


726  OPERATIVE    SURGERY. 

the  clieek  to  the  maxilla.  The  division  of  the  bone  is  best 
accomplished  by  a  chisel  and  mallet,  the  section  being  made 
horizontally.  If  the  reflection  of  the  soft  parts  be  carried  up 
to  the  level  of  the  floor  of  the  nares,  the  nasal  cavity  can  be 
readily  opened  up  from  the  mouth. 

The  broad  rectangular  retractor  used  in  certain  abdominal 
operations  is  very  useful  in  holding  up  the  tissues  of  the 
cheek. 

2.  If  it  be  considered  desirable  to  remove  all  that  portion 
of  the  superior  maxilla  which  lies  below  the  infraorbital 
foramen,  the  operation  introduced  by  Guerin  ("  Elements  de 
Chu'ur.  Operat,"  6th  ed.,  1881,  page  267)  may  be  carried  out. 
This  procedure  was  modified  later  b}^  Maisonneuve,  and  is 
sometimes  known  as  Maisonneuve's  operation. 

An  incision,  with  the  convexity  outwards,  is  made  from 
the  ala  of  the  nose  to  the  angle  of  the  mouth,  and  is  so 
placed  as  to  follow  the  line  of  the  features  (Fig.  219,  b).  The 
soft  parts  are  dissected  up,  and  the  nostril  opened.  The  malar 
process  of  the  superior  maxilla  is  laid  bare.  A  narrow  saw  is 
now  introduced  into  the  nose,  and  is  made  to  saw  the  whole 
maxilla  in  a  horizontal  line.  The  saw-cut  passes  below  the 
infraorbital  canal  and  well  above  the  teeth,  and  escapes 
externally  through  the  maxiUary  tuberosity  (Fig.  215,  e).  The 
next  step  is  to  detach  the  soft  palate  from  the  hard  through 
the  mouth,  by  means  of  a  transverse  incision  made  at  the 
level  of  the  last  molar  tooth.  A  middle  incisor  tooth  having 
been  removed,  the  hard  palate  is  divided  in  the  median  line 
by  a  narrow  saw  introduced  through  the  nose  (Fig.  215,  c).  The 
piece  of  bone  thus  isolated  is  then  loosened  by  an  elevator 
and  wrenched  out  Avith  the  lion  forceps.  Guerin  made  large 
use  of  cutting  forceps,  but  at  the  present  day  both  saw  and 
forceps  would  probably  be  ref)laced  by  the  chisel.  This 
operation  is  said  to  have  been  followed  by  excellent  results, 
and  to  have  led  to  but  little  deformity. 

3.  If  the  whole  of  the  maxilla  be  removed  with  the 
exception  of  the  orbital  plate,  the'  median  incision  should  be 
employed,  with  the  omission  of  the  horizontal  suborbital  part 
of  the  cut.  The  nasal  process  of  the  maxilla  is  divided  close 
to  its  origin  from  the  main  bone.  A  horizontal  cut  is  made 
with  the  chisel  throu<j:h  the  iaAv  between  the  orbital  mai'irin 


EXCISION   OF    UPPER   JAW.  727 

and  the  infraorbital  foramen,  and  the  malar  bone  is  divided 
obliquely  close  to  its  articulation  mth  the  maxilla. 

4.  When  the  orbital  and  nasal  parts  of  the  upper  jaw  are 
involved,  and  the  lower  alveolar  portion  is  sound,  the  latter 
may  be  preserved  by  the  method  thus  described  by  Mr. 
Jacobson : — "  A  cheek-fiup  being  reflected  by  an  incision 
through  the  lip  and  upwards  to  the  inner  canthus  along  the 
nose,  the  nasal  and  malar  processes  are  divided,  Avhile  the  eye 
is  duly  protected.  A  horizontal  saw-cut  is  then  made  above 
the  alveolar  process,  outwards  from  the  nose,  and  another 
carried  upwards  from  the  outer  end  of  this,  to  join  the  incision 
through  the  malar  process,  being  made  either  with  the  saw  or 
chisel.  The  piece  of  bone  thus  mapped  out  is  loosened  with 
a  chisel  or  elevator,  and  either  prised  out  with  the  latter 
instrument  or  WTenched  downwards  and  outwards  with  the  lion 
forceps."     (See  "  The  Operations  of  Surgery,"  1889,  page  296.) 

THE    REMOVAL   OF   BOTH   SUPERIOR   MAXILLiE. 

This  operation,  which  can  but  very  rarely  indeed  be 
justifiable  in  actual  practice,  may  be  carried  out  by  means  of 
the  median  incision  performed  upon  either  side  of  the  nose, 
just  as  in  removing  either  the  left  or  the  right  bone. 

The  steps  of  the  proceeding  are  similar  to  those  already  de- 
scribed, save  that  the  palate  process  is  now  divided  with  the  saw. 

THE   AFTER-TREATMENT. 

The  gauze  plug  employed  should  not  be  large  enough  to 
bulge  out  the  cheek  and  cause  a  strain  upon  the  sutures.  It 
should  be  removed  in  twenty-four  hours,  as  it  soon  becomes 
offensive  if  retained. 

Every  possible  care  should  be  taken  that  the  mouth  and 
the  wound  cavity  are  kept  clean. 

The  patient  should  be  raised  up  in  bed  by  means  of  a 
bed-rest,  so  as  to  facihtate  the  escape  of  discharges.  He  should 
rinse  out  the  mouth  very  frequently  with  some  antiseptic 
solution.  Carbolic  acid  (1  in  CO  or  80)  answers  admirably. 
Twice  or  three  times  a  day  also  the  cavity  should  be  well 
washed  out  with  a  like  solution  from  an  irrigator  provided 
with  a  wide-mouthed  nozzle. 

The  surface  Avound  should  be  kept  dry,  and  dusted  with 
iodoform. 


7'2S 


OPERATIVE    SURGEltY. 


The  feeding  of  the  patient  is  a  matter  of  the  greatest 
importance.  He  may  be  fed  for  the  first  day  or  tAvo  with  the 
cesophageal  tube.     Tliroiigh  this  tube,  milk,  beatcn-up  eggs, 

beef- tea,  and  brandy  can  be 
administered  as  frequently 
as  desired. 

If  necessary,  this  mode 
of  taking  nourishment  may 
be  supplemented  by  nutrient 
enemata. 

When   the    patient   can 
swallow  food  without  assist- 
ance— and  he  may  be  able 
to  do  so  from  the  first — the 
mouth  must  be  Avashed  out 
after  each  time  food  is  taken. 
The    skin    wound    gen- 
erally   heals    well    enough, 
and,     if    no    complications 
arise,  the  patient  may  be  up 
in  a  fortnight. 
When  the  Avound  is  quite  sound,  the  question  of  fitting  an 
artificial  palate  or  tooth-plate  has  to  be  considered. 

Results. — Mr.  Butlin  has  very  fully  investigated  the  re- 
sults of  this  operation,  basing  his  conclusions  upon  the  study 
of  108  cases.  He  gives  the  immediate  mortality  of  the 
operation  as  30  per  cent.  The  causes  of  death — in  order 
of  frequency — are  exhaustion,  erysipelas  or  pyaemia,  lung 
troubles,  meningitis. 

Most  of  the  operations  were  performed  for  malignant 
disease,  with  the  terrible  result  that  only  four  can  be  claimed 
to  have  been  successful — i.e.,  to  have  exhibited  no  return 
after  an  interval  of  three  3'^ears. 

Dr.  Joseph  Bryant  {Annals  of  Surgery,  May,  1890)  claims 
that  the  iunnediate  mortality  of  the  operation  is  only  14 
per  cent.  He  founds  this  statement  upon  an  analysis  of 
230  cases,  but  the  observation  is  not  supported  with  sufficient 
detail  The  terrible  deformity  which  may  be  expected  to 
result  when  both  bones  are  removed  is  illustrated  by  the  case 
depicted  in  Fig.  216. 


I'ig.  21(i. — ASPECT  OF  PATIENT  AFTER  EE- 
MOVAL  OF  THE  UPPER  JAW  ON  BOTH 

SIDES.  (Affer  Bnui.ii..) 


729 


CHAPTER    XXII. 

Operations   upon  the   Upper  Jaw   in   connection   with 
THE  Treatment  of  Naso-Pharyxgeal  Polypus. 

OSTEO-PLASTIC   RESECTION   OF   THE    UPPER   JAW. 

The  naso-pliaryngeal  polyp,  with  which  these  operations 
are  concerned,  is  that  fibrous  or  sarcomatous  growth  which, 
taking  origin  from  the  roof  of  the  pharynx  or  nasal  cavity,  is 
apt  to  grow  almost  without  limit,  to  till  the  naso-pharyngeal 
space,  to  displace  and  thin  the  facial  bones,  and  to  give  rise 
to  considerable  haemorrhage.  The  actual  method  employed 
to  remove  these  growths  when  they  have  been  exposed  is  a 
matter  of  comparatively  small  importance,  and  will  vary  with 
the  practice  of  each  individual  surgeon.  Some  advocate  avul- 
sion— i.e.,  the  grasping  of  the  pedicle  of  the  tumour  and  its 
removal  by  tearing ;  others  employ  the  ligature,  or  the  wire 
ecraseur ;  some  make  use  of  the  galvanic  loop ;  and  others 
detach  the  base  of  the  growth  by  means  of  a  rugine. 

The  difficulty  is  not  in  dealing  with  the  base  or  pedicle  of 
the  tumour,  but  in  exposing  it.  If  only  the  root  or  point  ol 
origin  of  the  polyp  can  be  reached,  the  main  problem  in  the 
matter  of  treatment  will  be  solved. 

The  operations  which  are  about  to  be  described  have 
simply  for  their  object  the  proper  exposure  of  the  pedicle  of 
the  polyp,  or  such  exposure  as  will  enable  the  root  of  the 
growth  to  be  dealt  with. 

It  cannot  be  said  that  on  the  whole  they  are  very  satis- 
factory procedures,  but  on  the  other  hand  it  must  be  acknow- 
ledged that  the  difficulties  to  be  surmounted  are  considerable. 

Some  of  the  operations  consist  in  removing  portions  of 
the  superior  maxilla.  In  not  a  few  instances  the  whole  of  the 
bone  upon  one  side  has  been  sacrificed  in  order  to  expose  the 
pedicle  of  the  tumour.     Other  measures  consist  in  partially 


730  OPERATIVE    SURGERY. 

separating  some  portion  of  the  bone,  and  in  replacing  it  after 
the  growth  has  been  dealt  with.  These  operations  are 
generally  mcluded  under  the  terms  osteo-plastic  resection, 
temporary  resection,  "  luxation  temporaire." 

The  origin  of  the  osteo-plastic  resection  is  ascribed  to 
Huguier  about  1852  and  1854,  and  the  first  operations 
appear  to  have  been  performed  by  himself  and  by  Langen- 
beck  in  1861  — a  different  method,  however,  having  been 
adopted  by  each. 

These  various  operations  are  attended  with  considerable 
danger  in  the  severer  class  of  case.  The  main  trouble  is  from 
haemorrhage,  which  may  be  desperate. 

In  cases  in  which  much  bleeding  is  anticipated,  and 
in  which  the  growth  is  large  and  prominent  towards  the 
pharjmx,  it  is  the  usual  practice  to  perform  laryngotomy  or 
tracheotomy,  and  to  plug  the  opening  of  the  larynx,  or 
to  use  a  Trendelenburg's  tampon.     (See  page  717.) 

Not  a  few  patients  have  died  of  meningitis.  Others  have 
succumbed  to  septicaemia,  or  have  died  apparently  of  mere 
exhaustion.     A  recurrence  of  the  growth  has  been  common. 

The  retro-maxillary  region  may  be  reached  in  more 
than  one  way.  It  may  be  approached  through  the  palate, 
or  through  the  anterior  wall  of  the  nasal  fossae,  or  through 
the  maxilla. 

The  operations  about  to  be  described  will  be  divided 
into  three  categories,  according  as  the  pedicle  of  the 
polyp  is  approached  or  the  naso-pharyngeal  region  entered — 

1.  By  the  palatine  route. 

2.  By  the  nasal  route. 

3.  By  the  maxillary  route. 

It  will  be  seen  that  this  division  is  convenient,  although 
not  anatomically  very  precise. 

1.   THE    PALATINE   ROUTE. 

Nelaton's  Operation. — The  mouth  having  been  widely 
opened  Ijy  means  of  a  Mason's  gag,  a  median  incision  is 
made  along  the  soft  palate  and  uvula  so  as  to  bisect  them 
completely.  This  incision  is  carried  forwards  upon  the  hard 
palate,  until  it  reaches  a  point  half-way  to  the  alveolus. 
At    the    termination    of    this    median    cut,   two    transverse 


OPERATIONS  FOB  NASO-PHABYNGEAL  POLYP.      731 

incisions  are  made   which   incline   a   little   backwards    (Fig. 
217,  A). 

The  two  flaps  of  muco-periosteiim  thus  marked  out 
upon  the  hard  palate  are  now  dissected  up  with  the 
rugine.  The  soft  palate  is  detached  from  the  hard,  and 
the  exposed  portion  of  the  latter  is  then  removed  with 
the  chisel  and  mallet  in  the  form  of  a  quadrilateral 
piece  of  bone.  The  nasal  mucous  membrane  is  divided, 
and  as  much  of  the  vomer  removed  as  is  necessary.  An 
entrance  into  the  naso-pharjaigeal  region  is  thus  effected. 
After  the  polyp  has  been  dealt  Avith,  the  cleft  in  the 
palate  is  closed  by  staphyloraphy.  (See  Bull,  de  la  Soc 
de  Chir.,  t.  i.,  page  159.) 

Ohalot's  Operation.  —  The  attachments  of  the  upper 
lip  are  separated  from  the  bone  after  the  surgeon  has 
divided  transversely  the  fold  of  mucous  membrane  be- 
tween the  gum  and  the  lip  at  the  level  of  the  anterior 
nasal  spine.  The  nasal  fossae  are  opened  in  this  way 
from  the  front. 

The  canine  tooth  on  each  side  is  in  the  next  place 
removed. 

The  mouth  is  now  well  opened  with  a  gag,  and  two 
incisions  are  made  through  the  muco-periosteum  of  the 
hard  palate.  These  incisions  are  placed  one  on  each 
side.  They  start  from  the  gap  formed  by  the  loss  of  the 
canine  teeth,  terminate  behmd,  where  the  hard  palate  ter- 
minates, and  in  their  course  keep  close  to  the  alveolus  (Fig. 
217,  b).  The  alveolus  and  the  hard  palate  are  now  divided 
from  before  backwards  in  the  Hne  of  this  incision  by  means 
of  a  chisel  and  mallet. 

The  large  piece  of  bone  thus  isolated  is  separated 
from  its  connections  with  the  vomer  and  nasal  mucous 
membrane,  and  is  turned  do-\\Ti  into  the  mouth  like  a 
trap-door,  the  hinge  of  the  door  being  at  the  junction  of 
the  hard  palate  with  the  velum. 

After  the  polyp  has  been  removed,  the  displaced  bone 
is  restored  to  its  former  position,  and  may  be  maintained 
there  by  a  wire  suture  passed  on  either  side  through  the 
alveolus  (Chalet's  "  Nouveaux  Elements,"  Paris,  1886). 

Comment.  —  It    is    claimed    for    these    operations    that 


732 


OPERATIVE    SURGERY. 


they  leave  no  deformity  of  tlie  face,  and  do  not  interfere 
with  mastication.  Nelaton's  procedure  is  much  the  less 
severe,  but  very  little  room  is  provided  for  manipulation. 
The  aperture  made  is  some  way  back  in  the  mouth,  and 
a  view  of  the  operation  area  can  only  be  obtained  with 
much  difficulty.      In  Chalot's  operation,  considerable   injury 


Fig.  217. — A,  Nelaton's  operation  for  nasal  polyi^us  ;  B,  Chalot's  operation  for 
nasal  polypus. 


is  inflicted  upon  the  hard  palate ;  but  a  larger  opening  is 
made,  and  it  is  placed  well  forwards,  and  therefore  in  a 
much  more  convenient  situation.  It  will  be  obvious,  how- 
ever, that  if  much  bleeding  occur  the  displaced  palate  will 
form  a  very  troublesome  and  obstructive  foreign  body  in 
the  mouth,  and  the  operation  could  scarcely  be  safe  unless 
a  preliminary  tracheotomy  had  been  performed  and  the 
larynx  plugged.  These  operations  have  not  been  very  ex- 
tensively  employed.      They  are   not   suited    for    the    larger 


OPERATIONS  FOR  NASO-PHARYNGEAL  POLYP.      733 

polypi,  nor  for  those  whose  attachments  are— as  is  usually 
the  case — high  up. 

Annandale's  Operation. — Professor  Annandale  has  de- 
monstrated {Lancet,  January  2G,  l!SS9)  that  when  the 
alveolar  margin  and  palatal  portions  of  the  upper  jaw  have 
been  divided  along  their  centre  from  before  backwards,  and 
the  bony  septum  of  the  nose  cut  through  (the  anterior 
nares  having  first  been  exposed  by  Rouge's  plan),  the  two 
portions  of  the  upper  jaw  can  be  separated  to  the  extent 
of  from  half  an  inch  to  one  inch,  so  as  to  give  access  to 
the  posterior  nares  and  base  of  the  skull.  Professor 
Annandale  reports  three  examples  of  the  operation.  In 
one  a  preliminar}'  tracheotomy  was  found  necessary.  All 
three  patients  recovered. 

The  following  are  the  steps  of  the  operation : — 

1.  The  anterior  nares  are  exposed  by  freely  dividing  the 
mucous  membrane  connecting  the  upper  lip  with  the 
superior  maxilla,  and  turning  the  lip  upwards  according  to 
the  plan  of  Rouge  (page  736). 

2.  The  bony  septum  of  the  nose  is  divided  along  its 
attachment  to  the  maxilla  with  cutting  forceps. 

3.  A  gag  having  been  introduced,  an  incision  is  made 
through  the  muco-periosteal  covering  of  the  hard  palate  in 
the  median  line.  A  key-hole  saw  is  then  introduced 
through  the  nose,  and  the  alveolar  margin  of  the  upper 
jaw  and  the  entire  hard  palate  are  sawn  through  in  the 
same  Ime.  It  may  be  necessary  to  extract  an  mcisor  to 
effect  this.  The  soft  palate  may  or  may  not  require 
division.  This  will  depend  upon  the  size  and  attachments 
of  the  growth.  In  two  of  the  reported  cases  it  was  divided ; 
in  one  it  was  not. 

4.  The  right  and  left  halves  of  the  maxilla  are  now  forcibl}^ 
separated,  and  by  means  of  the  linger  or  a  periosteal  elevator 
the  secondary  connections  of  the  growth  are  freed. 

5.  Through  the  gap  the  polyp  is  now  removed.  For 
this  purpose  Annandale  used  strong  forceps,  assisted  b}-  a 
periosteal  elevator  and  a  sharp  spoon. 

6.  When  the  tumour  has  been  removed,  a  plug  of  lint 
soaked  in  carbolic  acid  and  well  dusted  with  iodoform  is 
introckiced  into  the  cavity  left  b}-  the  removal  of  the  polyp. 


734  OPERATIVE    SURGERY. 

7.  The  two  portions  of  the  upper  jaw  are  brought 
together  again,  and  secured  by  one  wire  suture  through 
the  alveolar  margin  of  the  bone.  The  cleft  in  the  soft 
palate  is  closed  by  two  or  more  horse-hair  sutures. 

Comment.  —  This  .  operation  affords  probably  the  most 
satisfactory  method  of  reaching  a  naso-pharyngeal  polyp 
from  the  palate.  It  does  not  involve  a  great  disturbance 
of  the  parts,  there  is  no  loss  of  bone,  and  no  deformity  is 
produced.  As  the  section  is  made  in  the  median  line,  there 
is  less  bleeding.  Should  it  become  evident  that  a  more 
extensive  operation  will  have  to  be  carried  out,  this  pro- 
cedure may  be  converted  into  the  first  step  of  an  operation 
for  the  removal  of  the  whole  or  a  part  of  the  maxilla. 
There  are  the  objections  that  the  surgeon  has  to  operate 
in  a  confined  space,  and  that  the  opening  into  the  naso- 
pharynx is  at  a  considerable  distance  from  the  usual  site  of 
the  attachment  of  the  tumour. 

2.    THE    NASAL   ROUTE. 

Desprez's  Operation.  —  In  this  operation  the  cartila- 
ginous part  of  the  nose  is  turned  over  to  one  side,  its 
connections  having  been  divided  upon  the  opposite  side. 
The  surgeon  first  defines  the  margin  of  the  bony  nostril, 
i.e.,  the  lower  border  of  the  nasal  bone  and  the  free 
border  of  the  nasal  process  of  the  maxilla. 

The  skin  is  incised  on  one  side  of  the  nose  parallel  to 
this  line  and  a  little  below  it  The  incision  commences 
near  the  middle  line,  is  carried  down  to  the  groove  which 
separates  the  cheek  from  the  nostril,  and  is  made  to  end 
in  the  orifice  of  the  opposite  side. 

The  cartilaginous  part  of  the  nose  is  now  separated  from 
the  bony  part  by  means  of  scissors  curved  on  the  flat ;  the 
nasal  septum  is  separated  at  its  inferior  attachments  as  far 
as  is  needed,  and  the  end  of  the  nose  thus  freed  is  forced 
over  to  the  opposite  side.  To  obtain  still  more  room,  the 
turbinated  bones  may  be  removed  in  whole  or  in  part 

After  the  polyp  has  been  scciu-ed  the  nose  is  brought  back 
into  [»]acc,  and  the  skin  incision  is  carefully  closed  by  sutures. 

Lawrence's  Operation.  —  In  this  procedure  the  nasal 
cavity   is   exposed    l)y   detaching   the    nose   and    turning   it 


OPERATIONS  FOB  NASO-PHARYNGEAL  POLYP.      735 


iipwarrl fi.  An  incision  is  mado  along  each  side  of  the  nose, 
commencing  at  a  point  just  internal  to  the  lachrymal  sac 
and  terminating  at  the  junction  of  the  ala  nasi  and  the 
lip.  This  incision  is  can'ied  into  the  nasal  cavity  by  cut- 
ting through  the  nasal  bones  and  the  nasal  process  of 
the  maxilla  with  bone  forceps. 

The  septum  is  next  divided,  and  the  nose  is  turned  up 
so  that  the  posterior  part  of  the  cavity  can  be  reached. 
(See  Medical  Times  and  Gazette,  1SG2,  vol.  ii.,  page  491.) 

Langenbeck's  Operation. — The  following  brief  accoimt  of 
this  procedure  is  derived  from  Mr.  Jacobson's  work.  Here 
also  the  displacement  of  the  bones  is  upwards.  The  soft 
parts  are  divided  by  an  incision  reaching  from  the  centre  of 
the  root  of  the  nose  obliquely  downwards  and  outwards  on 
one  side  of  the  nose  on  to 
the  cheek,  and  ending  at  a 
point  external  to  the  ala 
nasi  (Fig.  218,  a).  The  soft 
parts  on  the  upper  lip  of  the 
wound  having  been  raised 
upwards  and  outwards,  a 
vertical  incision  is  made 
upwards,  through  the  nasal 
bone  to  the  nasal  spine  of  B.. 
the  frontal,  and  a  second 
outwards  from  the  bony 
margin  of  the  anterior 
nares  to  the  margm  of  the 
orbit.  The  nasal  bone  and 
the  nasal  process  of  the 
superior  maxilla  are  then 
forcibly  displaced  upwards, 
together  with  their  peri- 
osteum, being  still  con- 
nected with  the  frontal 
bone  by  skin,  periosteum, 
and  mucous  membrane.  When  the  polyp  has  been  removed, 
the  bones  are  replaced  and  the  skhi  united  by  suture. 

OUier's  Operation. — In  this  measure  the  nose  is  separated 
and  displaced  downwards. 


A.__J 


Fig.  218. — OPERATIONS  FOR  NASO-PHAET:^- 
GEAL  POLYPUS. 


Langeiibeck's    operation  ; 
operation. 


Boeckel's 


7o6  OPERATIVE    SUBGEBY. 

The  incision  commences  in  the  groove  where  the  ala  joins 
the  cheek,  is  carried  up  along  the  side  of  the  nose,  is  then 
made  to  pass  over  the  root  of  the  nose  between  the  e3"es,  and 
to  follow  a  symmetrical  course  upon  the  other  side  of  the  face 
(Fig.  219,  A). 

A  fine  bone-saw  is  now  taken,  and  the  nasal  bones  are 
sawn  in  the  line  of  the  skin  incision. 

As  large  a  section  of  the  bones  is  made  as  is  possible. 
Indeed,  the  saw  may  be  carried  sufficiently  far  back  to  just 
avoid  the  lachrymal  sac  and  nasal  duct.  The  nose  thus 
separated  is  turned  downwards.  The  septum  is  pressed  aside, 
and  the  site  of  the  operation  reached.  The  operation  is  con- 
cluded by  adjusting  the  part  with  sutures. 

Comvient. — Of  the  comparative  merits  of  these  various 
measures  there  is  little  to  be  said.  As  a  whole,  they  must  be 
of  very  limited  application,  and  are  suited  rather  for  nasal 
than  for  naso -pharyngeal  polj^pi.  They  provide  but  little 
room ;  and  if  the  attachment  of  the  growth  be  to  the  base  of 
the  skull,  at  the  roof  of  the  pharynx  these  operations  can 
avail  but  little.  If  the  attachment  be  to  the  anterior  part  of 
the  nasal  roof,  however,  one  or  other  of  these  u^easnres  may 
be  employed.  The  published  cases  are,  up  to  the  present 
time,  very  few. 

Rouge's  Operation. — This  procedure  may  be  conveniently 
considered  in  this  place. 

It  aftbrds  a  means  of  gaining  a  free  access  to  the  nasal 
cavities  without  making  a  scar  upon  the  face. 

The  operation  Avould  scarcely  be  carried  out  in  dealing 
with  naso-pharyngeal  polypi,  except  in  cases  in  which  the 
growth  was  very  small,  and  easily  reached  from  the  front.  It 
is,  however,  of  admirable  service  in  dealing  with  cases  of 
obstinate  ozaena,  in  affording  a  means  of  fully  examining  the 
nasal  cavities,  in  removing  carious  bone,  in  dealing  with  lupus 
of  the  nasal  mucous  membrane,  and  in  treating  the  more 
troublesome  forms  of  nasal  polypus. 

The  operation  was  described  by  Dr.  Rouge  in  1873 
("  Nouvelle  Methode  pour  Ic  Traitement  Chirurgical  de 
rOzene,"  Lausanne,  1878). 

Precautions  having  been  taken  to  prevent  the  flow  of 
blood  into  the  pharynx  and  larynx,  the  up])er  lip  is  forcibly 


OPERATIONS    FOB   NASO-PHABYNGEAL    POLYP.      737 


raised  by  an  assistant,  who,  leaning  over  the  patient's  head, 
draws  up  the  Up  by  taking  hold  of  it  at  the  angles  of  the 
mouth. 

The  surgeon,  with  scissors  curved  on  the  flat,  frees  it  from 
the  maxilla  by  cutting  the  mucous  membrane  along  its  line 
of  reflection,  from  opposite  the  bicuspids  of  one  side  to  a 
corresponding  point  on  the  other.  The  scissors  must  be  kept 
close  to  the  bone.  The  cartilaginous  septum  is  next  detached 
from  the  anterior  nasal  spine,  and  the  alar  cartilages  are  se]3ar- 
ated  from  their  connections  with  the  maxilla.  The  adjacent 
parts  of  the  cheek  must  be  separated  as  far  as  is  necessary, 
m  order  that  the  upper 
lip,  together  with  the 
nose,  may  be  turned  up- 
wards towards  the  fore- 
head, and  the  anterior 
nares  well  exposed  for 
examination. 

After  the  operation 
the  parts  are  merely  re- 
placed. No  sutures  are 
needed.  The  nose  may 
be  carefully  and  accu- 
rately supported  by 
means  of  cotton-wool 
and  a  bandao-e,  and  the 
mouth  should  be  kept 
clean  by  some  antiseptic 
wash. 


A- 


Fiff.    219. 


OPEBATIONS    FOB    NASO-PHAETNGEAL 
POLTPUS. 


A,  Ollier's  operation ;  b,  Guerin's  operation ;  c, 
Langenbeck's  operation. 


3.  THE  MAXILLARY  ROUTE. 

Boeckers  Operation. 

—  In     performing     this 

operation  a  considerable  part  of  the  bone  around  the  margin 

of  one  nostril  is  sacrificed. 

The  skin  incision  commences  near  the  root  of  the  nose, 
and  is  carried  obliquely  along  the  side  of  the  nose  to  the 
groove  between  the  nostril  and  the  cheek.  It  is  then  made  to 
curve  backwards  and  doAvnwards  for  some  little  way  upon  the 
cheek.     From  the  point  of   commencement  of   the  incision 


738  OPERATIVE    SUBGERY. 

another  cut  is  carried  inwards,  wliicli  follows  the  lower  margin 
of  the  orbit.  A  tongue-shaped  flap  of  skin  is  thus  defined,  the 
base  of  which  is  outwards  (Fig.  218,  b). 

The  incision  is  carried  well  down  to  the  bone  throughout. 
With  a  small  rugine  the  periosteum  is  separated  from  the 
lower  part  of  the  nasal  bone,  and  from  the  whole  width  of  the 
nasal  process  of  the  maxilla,  care  being  taken  to  avoid  the 
lachrymal  sac  on  the  one  hand,  and  the  infraorbital  nerve 
on  the  other.  A  chisel  is  now  entered — first  to  the  inner  side 
of  the  infraorbital  canal,  and  the  maxilla  is  divided  nearly 
vertically,  the  incision  involving  the  whole  of  the  wide  base  of 
the  nasal  process  and  a  little  of  the  bone  beyond.  This 
chisel-cut  extends  into  the  nasal  cavity,  reaching  it  to  its 
floor. 

The  bone  is  now  divided  with  the  chisel  just  in  front  of 
the  lachrjnnal  sac,  and  again  through  the  upper  part  of  the 
nasal  process  and  the  lower  part  of  the  nasal  bone,  the  instru- 
ment once  more  reaching  the  cavity  of  the  nose.  The  portion 
of  bone  thus  marked  out  is  now  entirely  removed.  The  lines 
of  the  bone  incisions  and  the  part  excised  are  shown  in 
Fig.  215,  D.  The  portion  removed  measures  about  3  cm.  in 
vertical  length,  and  about  2  cm.  in  width. 

The  nasal  cavity  is  now  extensively  exposed,  and  to  obtain 
more  room  the  inferior  and  middle  turbinated  bones  are  re- 
moved. After  the  polyp  has  been  dealt  with;  the  flap,  com- 
posed of  the  periosteum  and  the  soft  parts,  is  carefully 
brought  into  position  by  means  of  sutures. 

Langenbeck's  Operation.  —  A  tongue-shaped  flap  is 
marked  out  from  the  tissues  of  the  face  ;  a  large  part  of  the 
maxilla  is  separated  by  the  saw,  and  the  fragment,  together 
with  the  soft  parts  which  cover  it,  is  temporarily  displaced 
inwards.     The  following  are  the  steps  of  the  operation : — 

Two  semilunar  incisions,  both  convex  downwards,  are  made 
across  the  face.  They  are  widely  separated  towards  the  middle 
line,  V)ut  meet  externally.  The  upper  of  the  two  incisions  starts 
from  the  root  of  the  nose,  is  carried  just  below  the  inferior 
margin  of  the  orbit,  and  ends  a  little  behind  the  middle  of  the 
malar  bone.  The  lower  cut  starts  from  the  ala  of  the  nose, 
and,  curving  across  the  cheek,  joins  the  termination  of  the 
upper  incision. 


OPERATIONS    FOB   NASO-PHABYNGEAL    POLYP.     739 

The  outer  end  of  the  united  incision  may  be  then  con- 
tinued a  little  way  along  the  zygomatic  arch  (Fig.  219,  c). 

The  knife  is  carried  throughout  Avell  down  to  the  bone. 
The  intesniment  should  not  be  reflected,  nor  even  disturbed. 
By  means  of  a  rugine  the  periosteum  is  freed  along  the  lines 
of  the  incisions,  and  is,  moreover,  stripped  from  the  floor  of 
the  orbit  as  far  back  as  the  spheno-maxillary  fissure.  The 
origin  of  the  masseter  is  detached  from  the  exposed  part  of 
the  malar  bone.  The  soft  parts  are  left  almost  entirely  un- 
disturbed, and  the  flap  must  not  be  detached  from  the  sub- 
jacent bone  in  any  way. 

A  pointed  elevator  is  now  passed  below  the  zygomatic 
arch,  and  is  made  to  travel  horizontally  through  the  pterygo- 
maxillary  fissure  to  the  outer  wall  of  the  nasal  cavity.  Its- 
end  may  be  made  out  by  the  forefinger  introduced  through 
the  mouth. 

The  elevator  having  been  withdra-vvn,  a  key-hole  saw,  with 
the  cutting  edge  upwards,  is  inserted  along  the  tract  made  by 
the  elevator,  and  is  made  to  divide  the  zygomatic  arch,  as 
represented  by  the  malar  bone,  and  is  so  carried  through  that 
bone  as  to  enter  the  spheno-maxillary  fissure.  It  should  then 
follow  the  floor  of  the  orbit,  to  end  short  of  the  lachrymal 
bone  (Fig.  215,  f). 

(As  an  alternative,  the  bone  may  be  divided  in  the  line  of 
the  skin  cut,  and  the  orbital  plate  thus  spared.) 

The  saw  is  removed,  and  is  once  more  introduced  through 
the  ptery go-maxillary  fissure,  but  now  with  the  cutting  edge 
downwards.  It  is  made  to  saw  through  the  walls  of  the 
antrum,  and  to  enter  the  anterior  nares  close  to  the  nasal 
floor.  It  follows  very  nearly  the  line  of  the  lower  skin 
incision. 

An  elevator  is  once  more  introduced  into  the  pterygo- 
maxillary  fissure,  and  the  portion  of  the  maxilla  separated  is 
displaced  inwards,  together  with  the  skin  and  periosteum 
which  cover  it. 

The  nasal  bone  and  the  nasal  process  of  the  maxilla  form 
the  hinge  about  which  this  large  fragment  is  bent  (Fig.  215, 
F  f). 

The  piece  is  displaced  upwards  and  inwards  until  the 
free  portion  of  the  malar  bone  is  about  in  the  middle  of  the 


740  OPERATIVE    SUBGEBY. 

face.  The  naso-pharyngeal  cavity  is  now  well  exposed.  After 
the  polypus  has  been  removed  the  bone  is  replaced,  and  the 
wound  closed  by  many  points  of  suture.  No  sutures  are,  as  a 
rule,  needed  for  the  bone.  Its  slight  tendency  to  rise  up  can 
be  met  by  the  pressure  of  a  sponge.  No  drainage-tube  is  re- 
quired. A  chisel  may  be  employed  in  the  place  of  the  saw. 
As  the  bones  are  often  much  thinned  by  the  pressure  of  the 
tumour,  certain  of  the  steps  of  the  operation  may  be 
simplified. 

Other  Operations.  —  Naso-pharyngeal  polypi  have  been 
exposed  through  the  maxilla  by  removing  other  segments  of 
the  bone.  The  partial  excision  practised  by  Guerin,  and  de- 
scribed on  page  726,  has  been  not  infrequently  made  use  of 
m  this  connection. 

The  whole  of  the  maxilla  has  been  excised  for  the  purpose 
of  exposing  a  naso-pharyngeal  polyp.  For  the  same  purpose 
the  whole  bone  has  been  loosened  from  its  connections,  and 
has  been  replaced  after  the  polyp  had  been  removed. 

Gornment. — The  two  operations  described  provide  a  very 
fair  view  of  the  upper  naso-pharyngeal  region.  The  operation 
of  Boeckel  is  simpler,  and  possibly  less  dangerous,  but  it  pro- 
vides less  room  for  dealing  with  the  polypoid  growth. 

Langenbeck's  operation  has  been  extensively  employed, 
and  is  probably,  of  the  various  methods  described,  the  one 
most  frequently  carried  out. 

The  operation  is  difficult  and  tedious,  and  may  be  attended 
by  very  considerable  bleeding. 

In  both  these  procedures  the  alveolus  and  the  palate  are 
left  undisturbed.  The  oral  cavity  is  not  interfered  with,  and 
the  orbital  cavity  is  not  seriously  encroached  upon.  In  both 
cases,  however,  a  very  conspicuous  scar  must  result. 

Results. — So  far  as  the  complete  removal  of  the  polyp  is 
concerned,  the  best  results  have  followed  those  operations 
which  have  given  the  Avidest  view  of  the  naso-pharyngeal 
region.  Certain  of  the  measures  above  described  provide  but 
little  room,  and  much  of  the  surgeon's  work  is  done  in  the 
dark.  The  displaced  piece  of  bone — in  the  so-caUed  osteo- 
plastic resections — has  necrosed  in  whole  or  in  part.  Some 
patients  have  died  of  the  immediate  effects  of  the  operation, 
the  most   serious   element   being  haemorrhage ;  others  have 


OPERATIONS    FOB    NASO-PHARYNGEAL   POLYP.     741 

succumbed  to  meningitis,  others  to  pyaemia.  The  mortahty 
of  these  operations  has  been  roughly  estimated  at  about 
twenty-five  per  cent. 

It  must  be  confessed  that  recurrence,  even  after  what 
appears  to  be  a  very  complete  removal,  is  common. 

Out  of  thirty-nine  operation  cases  collected  by  Lincoln, 
recurrence  took  place  within  tAvelve  months  in  fourteen  cases, 
eight  deaths  followed  the  operation,  four  patients  may  be  said 
to  have  been  cured,  and  in  thirteen  the  conclusion  of  the  case 
is  not  noted. 


742 


CHAPTER   XXIII. 

Excision  of  the  Lower  Jaw.. 

The  circumstances  under  which  this  operation  is  carried  out 
are  nearly  identical  with  those  which  justify  like  excisions 
of  the  upper  jaw  (page  715). 

A  large  number  of  the  operations  are  partial,  and  only  in  a 
few  instances  is  it  necessary  to  remove  the  entire  bone,  i.e., 
both  the  right  and  left  portions  of  the  maxilla. 

A  concise  account  of  the  history  of  the  operation  is 
given  by  South  (Chelius's  "  Surgery,"  vol.  ii.).  Deadrick  (Amer. 
Med.  Rec,  vol.  vi.,  page  516,  1826)  was  the  first  who,  in 
1810,  cut  away  the  side  of  the  lower  jaw ;  in  1812  Dupuytren 
(Clinical  Lecture,  transl.  in  Lancet,  vol.  i.,  1833,  page  56) 
sawed  off  a  large  portion  of  the  front  of  the  jaw;  in  1816 
Anthony  White  (Chehus,  vol.  ii.,  page  991)  removed  half  a 
necrosed  jaw  from  the  socket;  in  1818  Astley  Cooper  ("Sur- 
gical Essays,"  part  i.,  page  179,  1818)  sawed  off  the  projecting 
part  of  the  chin  ;  in  1821  Graefe  {Graefe  and  Von  Waltlters 
Joum.,  vol.  iii.,  j^age  250, 1822)  removed  the  front  of  the  jaw, 
and  in  the  same  year  one  half  of  the  lower  jaw,  which  he 
exarticulated,  and  the  patient  lived.  Mott's  first  operation,  in 
which  half  the  jaw  was  removed,  by  sawing  through  the  chin 
and  across  the  ascending  branch,  was  jjerformed  in  March, 
1822  (New  York  Med.  and  Phys.  Joum.,  vol.  i.,  page  386)  ;  his 
second,  in  which  he  exarticulated  one  half,  in  May,  1822, 
the  patient  dying  on  the  evening  of  the  fourth  day. 

Anatomical  Points. — The  general  features  of  the  bone 
and  of  the  muscles  attached  to  it  need  not  here  be  considered. 
The  maxilla  is  composed  of  very  dense  hard  bone,  which  is 
somewhat  difficult  to  saw  or  to  cut  with  bone  forceps.  The 
bone  is  weakest  at  the  situation  of  the  bicuspid  teeth,  and 
strongest   at   the   symphysis.     Of  the  sockets  for  the  teeth, 


EXCISION  OF   LOWER   JAW.  743 

those  for  the  incisors  are  the  smallest,  that  for  the  canine  is 
the  widest  and  the  dee^^est. 

It  must  be  remembered  that  with  the  loss  of  the  teeth  by 
age  the  alveolar  part  of  the  bone  becomes  absorbed. 

The  parotid  gland  is  in  close  relation  with  the  temporo- 
maxillary  jomt  and  the  vertical  ramus  of  the  jaw. 

The  course  of  Stenson's  duct  across  the  masseter  is  re- 
presented by  a  line  drawn  from  the  lower  margin  of  the 
concha  to  a  point  midway  between  the  ala  of  the  nose  and 
the  red  margin  of  the  lip.  It  lies  about  a  tinger's-breadth 
below  the  zygoma,  having  the  transverse  facial  artery  above 
it,  and  the  facial  nerve  below  it.  The  facial  nerve  is  re- 
presented by  a  line  drawn  across  the  parotid  gland,  in  a 
direction  forwards  and  a  httle  downwards,  from  the  spot 
where  the  anterior  border  of  the  mastoid  process  meets  the  ear. 

The  facial  artery  crosses  the  lower  border  of  the  jaw  at  the 
anterior  margin  of  the  masseter  muscle. 

The  vessels  divided  in  excising  the  lower  jaw  are  the 
facial,  inferior  coronary  and  labial  (if  the  Hp  be  severed), 
mental,  masseteric,  inferior  dental,  and  mylo-hyoid. 

The  parts  in  danger  of  being  damaged  are  the  facial 
nerve,  the  internal  maxillary  arter}^,  temporo-maxillary  vein, 
auriculo-temporal  nerve,  external  carotid  artery,  gustatory 
nerve,  and  the  parotid,  submaxillary,  and  sublingual  glands. 

Instruments  Required. — The  same  as  for  excision  of  the 
upper  jaw,  with  the  addition  of  a  small  saw  with  a  movable 
back,  or  a  small  Butcher's  saw,  and  a  needle  in  a  handle  for 
securing  the  tongue  if  necessary. 

THE  REMOVAL  OF  ONE  HALF  OF  THE  LOWER  JAW. 

Operation. — The  patient  lies  upon  the  back,  with  the  head 
and  shoulders  raised,  and  with  the  trunk  close  to  the  edge  of 
the  table.  The  surgeon  stands  on  the  side  to  be  operated 
upon.  Some  tind  it  more  convenient  to  stand  on  the  patient's 
right  in  dealing:  with  either  side  of  the  maxilla. 

The  head  is  turned  to  the  sound  :  "de.  The  chief  assistant 
takes  his  place  opposite  to  the  surgeon.  A  second  helper 
stands  by  the  operator's  side. 

In  male  subjects  the  chin  will  have  been  already  shaved. 

1.    A  vertical   incision   is   made   through   the   tissues  of 


744  OPERATIVE    SURGERY. 

the  chin,  in  the  middle  hne,  starting  just  below  the  lip,  which 
is  not  divided.  From  the  lower  end  of  this  another  incision 
is  carried  along  and  just  below  the  inferior  border  of  the  jaw 
for  its  entire  length,  and  is  then  directed  upwards  along  the 
posterior  margin  of  the  ascending  ramus,  to  end  opposite  to 
the  lobule  of  the  ear  (Fig.  213,  c). 

The  incision  is  carried  throughout  down  to  the  bone, 
except  in  one  place,  viz.,  where  the  knife  crosses  the  facial 
artery.     Here  the  wound  is  only  skin  deep. 

After  the  incision  has  been  made,  the  surgeon  returns  to 
the  spot  indicated,  exposes  the  facial  artery  by  dissection, 
secures  it  between  two  ligatures,  and  divides  it. 

With  a  periosteal  elevator  or  rugine  the  muscles  attached 
to  the  external  surface  of  the  maxilla  are  rapidly  separated 
fi-om  the  bone,  and  are  turned  up  with  the  integuments  in  the 
form  of  a  flap.  The  separation  is  commenced  at  the  sym- 
physis, and  carried  backwards.  The  buccinator  and  masseter 
are  peeled  off  from  the  bone  in  this  part  of  the  operation.  The 
mental  and  masseteric  arteries,  together  with  some  smaller 
branches,  are  divided  at  this  stage. 

It  is  desirable  that  the  operator  should  keep  close  to  the 
bone. 

The  cavity  of  the  mouth  is  now  opened  by  dividing  the 
buccal  mucous  membrane  at  its  junction  with  the  alveolus. 

2.  The  surgeon  now  extracts  one  of  the  incisor  teeth — 
the  lateral  incisor  as  a  rule — and  with  a  key-hole  saw  divides  the 
jaw  vertically  in  the  line  of  the  gap  (Fig.  215,  g).  It  is  often 
more  convenient  to  saw  the  bone  nearly  through,  and  then 
to  complete  the  section  with  suitable  bone-cutting  forceps. 
More  or  less  of  the  genio-hyoid,  genio-hyo-glossus,  and  digas- 
tric muscles  will  be  disturbed  in  clearing  the  inner  surface  of 
the  bone. 

3.  The  anterior  extremity  of  the  divided  maxilla  is  now 
drawn  outwards,  and  with  a  blunt-pointed  knife  kept  close  to 
the  bone  the  surgeon  divides  the  attachment  of  the  mylo- 
hyoid muscle.  The  internal  pterygoid  muscle  is  reached,  and 
may  be  conveniently  separated  from  the  bone  by  means  of  a 
periosteal  elevator.  The  lower  border  of  the  maxilla  is  twisted 
outwards,  in  order  that  the  whole  of  the  attachment  of  the 
internal  pterygoid  muscle  may  be  dealt  with. 


EXCISION    OF    LOWER    JAW.  745 

The  inferior  dental  artery  and  nerve  are  exposed  and 
divided.  In  this  part  of  the  operation  care  must  be  taken  to 
avoid  injury  to  the  sub-lingual  and  sub-maxillary  glands. 

4.  The  anterior  part  of  the  jaw  is  now  forcibly  depressed, 
in  order  to  bring  the  coronoid  process  into  view  in  the 
posterior  part  of  the  wound. 

The  tendon  of  the  temporal  muscle  is  divided,  with 
scissors  curved  on  the  flat,  as  each  part  of  the  fibres  of  in- 
sertion is  successively  reached. 

Some  surgeons  divide  the  coronoid  process  with  a  chisel 
and  mallet,  and  subsequently  dissect  out  the  fragment  of  bone 
thus  isolated. 

The  jaw  is  still  further  depressed,  in  order  that  the  con- 
dyle may  be  brought  into  view. 

The  external  pterygoid  muscle  is  reached,  and  is  detached 
with  the  elevator  or  divided  with  scissors.  The  capsule  of 
the  joint  is  severed,  the  articulation  is  opened  and  the  condyle 
freed.  Throughout  this  stage  of  the  excision  the  jaw  should 
be  merely  depressed.  It  should  not  be  twisted.  If  it  be 
much  everted  or  rotated  out,  the  internal  maxillary  artery 
may  be  brought  into  contact  with  the  neck  of  the  bone,  and 
may  be  accidentally  divided  or  even  torn. 

It  only  remains  now  to  cut  the  bone  free  of  its  few  surviv- 
ing attachments,  which  are  represented  by  the  internal  lateral, 
stylo-maxillary  and  pterygo-maxillary  ligaments,  together  with 
more  or  less  fascia  and  the  remaining  fibres  of  the  outer 
pterygoid  muscle. 

AU  bleeding  having  been  checked,  the  wound  is  united 
with  silkworm -gut  sutures.  The  chin  part  of  the  incision 
should  be  adjusted  with  especial  care.  A  drainage-tube  may 
be  introduced  into  the  hinder  part  of  the  wound,  and  retained 
there  for  twenty-four  hours. 

A  dressing  composed  of  a  sponge  dusted  with  iodoform, 
and  kept  in  place  by  a  layer  of  wool  and  a  supporting  bandage, 
will  be  found  to  be  efiicient. 

Comment. — This  operation  admits  of  very  little  variation. 
The  whole  of  one  side  of  the  maxilla  has  been  removed  with 
success,  through  the  mouth. 

Upon  no  reasonable  grounds,  however,  can  this  method  be 
recommended.     It  is  true  that  no  skin-wound  is  made,  but 


746  OPERATIVE    SUBGEBT. 

on  the  other  hand  the  scar  resultmo-  from  the  usual  Avound 
is  not  distiguring,  nor  is  it  even  conspicuous.  In  attempting 
to  remove  the  maxilla  from  the  mouth,  the  surgeon  must 
find  his  movements  hampered.  Considerable  damage  must 
be  inflicted  upon  the  soft  parts  ;  there  is  great  risk  of  injuring 
the  internal  maxillary  artery,  and  efficient  drainage  is  not 
provided. 

If  the  operation  be  carried  out  as  advised,  there  can  be 
httle  need  of  adoj^ting  such  special  measures  for  meeting 
haemorrhage  as  the  ligature  of  the  external  carotid  artery,  or 
the  plugging  of  the  larynx  after  tracheotomy.  It  is  only 
when  deaUng  with  large  and  vascular  growths  that  any  such 
precautions  are  suggested. 

Some  surgeons  carry  the  skin  incision  entirely  through 
the  Up.  This  procedure,  although  it  renders  the  clearing  of 
the  bone  more  easy,  is  not  necessary.  Some  deformity  is  j)ro- 
duced,  and  the  adjustment  of  the  wound  cannot  be  so  care- 
fully carried  out.  The  point  is  not  of  primary  importance, 
and  in  dealing  with  a  large  growth  the  knife  may  very 
properly  be  carried  through  the  thickness  of  the  lip. 

Whenever  possible,  the  symphysis  should  be  saved.  If  it 
should  be  necessary  to  remove  the  median  part  of  the  bone 
with  the  genial  tubercles,  then  the  tongue  must  be  prevented 
from  falling  back  upon  the  larynx  by  means  of  a  suitable  silk 
ligature  passed  through  its  tip. 

If  the  coronoid  process  be  unduly  long,  or  if  it  be  pressed 
forwards  by  the  growth  of  the  tumour,  it  may  hitch  against 
the  malar  bone  when  the  bone  is  depressed,  and  in  such  case 
must  be  divided  with  the  chisel  or  bone  forceps. 

"  In  cases  where  the  jaw  has  been  extensively  thinned  or 
eroded  by  a  growth,  it  is  very  likely  to  fracture  under  the  de- 
pression which  is  required  to  bring  down  the  condyle.  If  this 
accident  occur,  removal  of  the  condyle  and  coronoid  process 
is  rendered  difficult,  as  the  latter  is  drawn  upwards  under 
the  zygoma  by  the  temporal  muscle.  The  removal  will  be 
fucihtated  by  dragging  them  down  with  hon-forceps  and 
detaching  the  temporal  tendon  with  blunt-pointed  scissors" 
(Jacobson). 

In  dealing  with  growths  of  the  maxilla  it  is  undesirable 
that  the  periosteum  should  be  saved. 


EXCISION   OF   LOWER    JAW.  747 

In  excision  for  necrosis,  however,  it  is  inipor^^ant  that  as 
little  of  that  membrane  as  possible  should  be  sacriticed. 

PARTIAL   EXCISIONS   OF   THE   LOWER  JAW. 

Considerable  portions  of  the  jaw,  but  more  especially  of 
the  alveolar  part  of  it,  can  be  removed  from  the  mouth. 
Such  operations  are  frequently  called  for  in  dealing  with 
some  of  the  many  forms  of  epulis.  Such  a  segment  as  is 
shown  in  Fig.  215,  h  can  be  readily  removed.  In  effecting 
excisions  of  this  limited  character  the  chisel  and  mallet  arc 
the  most  useful  instruments.  Or  the  saw  may  be  conveni- 
ently employed  for  the  vertical  incisions  in  the  bone,  and 
the  chisel  for  the  horizontal  cuts. 

It  is  well  that  the  teeth  in  the  involved  segment  should 
be  removed  should  any  still  remain.  The  surgeon  will  add 
greatly  to  the  difficulties  of  the  operation  if  he  attempts  to 
drive  a  chisel  or  a  saw  through  the  fangs  of  several  teeth. 

If  a  portion  of  the  body  of  the  bone  have  to  be  excised, 
then  it  is  always  well  to  approach  it  by  an  mcision  made 
along  the  lower  border  of  the  maxilla. 

Attempts  to  remove  considerable  segments  of  the  body 
of  the  bone  through  the  mouth  are  most  unsatisfactory,  lead 
to  a  needless  mangling  of  the  soft  parts,  to  much  bleeding, 
and  to  a  sloughy  pouch  in  the  floor  of  the  mouth. 

The  external  incision  enables  the  surgeon  to  reach  the 
bone  readily,  to  deal  with  it  in  the  simplest  manner,  and  to 
drain  the  wound  cavity  left  after  the  excision. 
^  ^Vhenever  possible,  a  portion  of  the  loAver  part  of  the  bone 
Si.ould  be  preserved,  or,  in  other  words,  the  lower  border 
should  never  be  divided  unless  it  is  inevitable. 

If  only  a  narrow  bar  of  bone  be  left  in  this  situation,  it 
will  prove  of  enormous  value,  not  only  in  the  after-treatment, 
but  also  in  so  far  as  the  resulting  deformit}^  is  concerned. 
The  free  use  of  the  chisel  enables  much  to  be  done  m  this 
direction. 

If  a  portion  of  the  maxilla,  through  its  whole  width,  has 
to  be  removed,  it  is  better,  as  Mr.  Heath  advises,  not  to 
complete  one  section  before  the  other  is  begun,  because  of 
the  loss  of  resistance  consequent  upon  breaking  the  continuity 
of  the  bone. 


748  OPERATIVE    SURGERY. 

Eacli  cut  should  be  carried  nearly  through  the  bone  by 
means  of  the  saw,  and  should  then  be  completed  with  the 
bone-forceps. 

"  The  removal  of  the  central  portion  of  the  jaw,"  writes 
Sir  William  MacCormac,  "  leads  to  considerable  fLuictional 
trouble  later,  from  the  difficulty  of  keeping  the  ends  apart 
and  preserving  the  parallelism  of  the  teeth.  This  must  be 
striven  for  by  the  use  of  suitable  apparatus,  but  the  result 
is  usuall}^  unsatisfactor}'-." 

THE  REMOVAL  OF  THE  WHOLE  OF  THE  LOWER  JAW. 

This  operation  has  been  performed  in  a  fair  number  of 
cases.  In  Weber's  table  twenty  cases  are  alluded  to.  The 
excision  is  reputed  to  have  been  first  carried  out  by  Blandin 
in  1848. 

The  procedure  requires  no  special  description.  The  ver- 
tical chin  incision  is  omitted,  and  the  knife  is  carried  along  the 
whole  of  the  lower  border  of  the  jaw  on  both  sides,  and 
terminates  posteriorly  in  the  manner  aheady  described. 

The  After-treatment. — The  general  features  of  the  after- 
treatment  have  been  alluded  to  in  dealing  with  the  upper  jaw. 
The  main  difficulty  is  to  keep  the  mouth  sweet.  A  large 
pouch  is  left  in  the  floor  of  the  mouth,  and  in  this  pouch 
food  and  the  secretions  of  the  mouth  must  of  necessity  collect, 
and  here  they  are  apt  to  decompose.  If  no  care  be  taken, 
this  pouch  becomes  the  seat  of  the  foullest  possible  sloughs. 

It  is  very  difficult  for  the  patient  to  wash  the  mouth  out 
efficiently,  as  it  is  painful  to  move  the  remaining  portion  of 
the  jaw,  and  even  to  move  the  head.  The  best  wash  is  a 
1-80  to  1-60  solution  of  carbolic  acid. 

For  the  first  few  days — if  possible,  for  the  first  ten  days — 
it  will  be  Avell  if  the  food  can  be  administered  through  a 
tube,  so  that  none  can  find  its  way  into  the  mouth.  If  this 
be  done,  and  if  the  mouth  be  washed  out  every  hour  with 
a  gentle  stream  from  an  irrigator,  the  parts  can  be  kept  in 
excellent  condition,  and  healing  will  proceed  rapidly. 

If  a  drainage-tube  be  emj)loyed,  it  should  be  removed  in 
twenty-four  hours,  and  the  escape  of  the  fluids  in  the  mouth 
through  the  skin- wound  should  not  be  encouraged  after  that 
time. 


OPERATIONS    FOR    ANCHYLOSIS    OF    THE    JAW.      749 

The  patient  should  occupy  the  sitting  position  as  much  us 
possible,  and  every  care  should  be  taken  that  he  is  well  fed. 
In  the  manner  of  feeding  I  have  usually  employed  the  nasal 
tube,  which  has  been  passed  after  a  little  cocaine  had  been 
introduced  into  the  nose  through  a  spray-producer. 

The  foulness  of  the  mouth  in  a  neglected  case  is  in- 
describable, and  the  persistent  attempt  to  avert  decomposition 
is  a  main  element  in  the  after-treatment. 

Results. — Mr.  Butlin  has  collected  104  cases  of  excision 
of  the  lower  jaw  for  tumour.  Of  these,  14  died  from  the 
effects  of  the  operation,  showing  a  mortality  of  rather  less 
than  14  per  cent. 

The  chief  causes  of  death  have  been  exhaustion,  pysemia, 
erysipelas,  and  lung  complications. 

Speaking  of  malignant  growths  (sarcomata)  of  the  lower 
jaw,  Mr.  Butlin  considers  that  the  prognosis  in  subperiosteal 
sarcoma  is,  in  spite  of  early  and  free  operation,  very  bad,  on 
account  of  the  rapidity  with  which  the  disease  involves  the 
neighbouring  structures,  and  recurs  after  removal 

In  cases  of  central  sarcoma  the  prognosis  is  not  so  bad, 
provided  that  the  resection  of  the  bone  has  been  free,  and 
especially  when  the  growth  is  of  the  giant-celled  or  myeloid  type. 

OPERATIONS    FOR   THE    RELIEF   OF   CLOSURE   OF   THE   JAW. 

These  operations  are  only  adapted  for  severe  cases  which 
have  resisted  all  milder  measures,  and  in  Avhich  the  closure 
or  the  anchylosis  is  such  as  to  cause  grave  inconvenience. 

So  far  as  the  bone  is  concerned,  two  operations  may  be* 
employed  in  dealing  with  this  condition. 

They  are  susceptible  of  modification,  but  they  represent 
elementary  principles  in  the  treatment. 

One  operation  would  be  ranked  with  cuneiform  osteoto- 
mies ;  the  other  has  been  described  as  an  excision  of  the 
temporo-maxillary  articulation. 

The  two  procedures  are  Esmarch's  operation,  and  the 
removal  of  the  condyle  of  the  lower  jaw. 

1.  Esmarch's  Operation. 

In  this  operation  a  wedge-shaped  piece  ot  bone  is  removed 
from  the  horizontal  portion  of  the  maxilla,  with  the  intention 
of  establishing  a  false  joint 


750  OPERATIVE    SURGERY. 

This  metliod  is  intended  for  those  cases  in  which  the 
trouble  is  not  limited  to  the  articulation.  It  is  especially 
employed  in  examples  of  closure  of  the  jaw  due  to  the 
contraction  of  cicatrices.  Such  contraction  is  apt  to  follow 
destructive  forms  of  inflammation,  of  which  cancrum  oris  is 
a  good  example. 

The  ivedge  of  bone  to  be  removed  must  be  taken  from  the 
horizontal  ramus  of  the  jaw,  anterior  to  the  masseter,  and  in 
front  of  the  contracted  tissues.  The  base  of  the  wedge  will 
be  below,  and  in  an  ordmary  case  in  an  adult  should  measure 
one  inch  and  a  quarter.  The  apex  is  at  the  alveolar  border, 
and  should  be  about  three-quarters  of  an  inch  in  width 
(Fig.  215, 1). 

An  incision  some  two  inches  in  length  is  made  along  the 
lower  border  of  the  jaw  at  the  spot  at  which  it  is  intended  to 
remove  the  wedge.  The  bone  having  been  well  exposed  and 
the  periosteum  divided,  a  wedge  of  bone  is  removed  with  a  key- 
hole saw,  aided  by  the  chisel  and  a  periosteal  elevator.  After 
all  bleeding  has  been  checked  the  wound  is  closed  by  sutures. 

It  is  essential  that  passive  movements  should  be  com- 
menced within  a  day  or  two  of  the  operation,  and  should  be 
regularly  maintained.  By  means  of  screw  gags  and  graduated 
pieces  of  cork  the  patient  should  be  encouraged  to  open  the 
mouth  as  wide  as  possible,  and  to  cultivate  active  movements 
of  the  new  joint.  Unless  care  be  taken  in  this  matter,  the 
trouble  is  very  apt  to  relapse.  If  great  pain  be  experienced 
in  moving  the  jaw,  then  the  passive  movements  may  be 
'  practised  under  gas  on  the  first  few  occasions. 

Very  good  results  have  been  obtained  by  this  method,  and 
very  useful,  though  one-sided,  masticatory  power  is  obtained. 

2.  Excision  of  the  Condyle  of  the  Jaw. 

This  operation  is  identical  with  the  so-called  excision  of 
the  teraporo-maxillary  articulation. 

It  has  been  carried  out  in  some  instances  of  suppurative 
joint-disease.  Usually,  however,  it  has  been  a^jplicd  to  ca^es 
of  chronic  rheumatoid  arthritis,  with  deformity  and  great 
impairment  of  movement,  and  to  cases  of  closure  of  the  jaw 
due  to  mischief  limited  to  the  articulation  itself 

A  vertical  incision  is  made  over  the  site  of  the  joint  and 
condyle.     It  is  placed  anterior  to  the  temporal  artery,  starts 


OPERATIONS   FOR    ANCHYLOSIS    OF    THE    JAW.      751 

at  the  lower  margin  of  the  zygoma,  and  ends  below,  just  short 
of  the  transverse  facial  artery.  The  temporal  artery  may  be 
considered  to  rim  about  a  finger's-breadth  in  front  of  the 
tragus,  while  the  transverse  facial  artery  is  a  little  less  than  a 
tinger's-breadth  below  the  zygoma. 

This  incision  may  be  joined  by  a  second  cut,  which, 
starting  from  its  upper  extremity,  follows  the  lower  margin  of 
the  zygoma  for  about  one  inch. 

The  triangular  flap  thus  marked  out  is  reflected  forwards. 
Care  is  taken  not  to  damage  any  branches  of  the  facial  nerve 
nor  any  lobe  of  the  parotid  gland. 

Such  fibres  of  the  masseter  as  come  into  view  are  sepa- 
rated from  the  zygoma,  the  capsule  of  the  joint  is  exposed  and 
opened,  and  the  condyle  brought  well  into  view. 

The  neck  of  the  condyle  is .  now  steadied  by  means  of  a 
small  blunt  hook,  and  is  divided  either  with  a  chisel  or  a  key- 
hole saw. 

The  condyle  is  then  seized  with  forceps,  and  is  twisted  out 
with  the  left  hand,  while  the  surgeon  severs  any  remaming 
connections  with  a  scalpel  held  in  the  right.  Throughout  the 
whole  operation  it  is  important  that  all  instruments  employed 
should  be  kept  close  to  the  bone. 

If  necessary,  a  little  more  bone  at  the  base  or  root  of  the 
condyle  may  be  removed,  or  it  may  be  desirable  to  repeat  the 
operation  upon  the  opposite  side.  The  tibro-cartilage  is  not 
removed. 

A  small  drain  may  be  introduced  and  retained  for  twenty- 
four  hours,  and  the  wound  closed  with  sutures.  Some  slifrht 
and  quite  temporary  facial  paralysis  may  exist  for  some  days 
after  the  operation. 

The  after-treatment  advised  in  connection  with  the 
previous  operation  must  be  here  employed. 

Unless  such  treatment  be  perseveringly  followed,  the  con- 
dition is  apt  to  relapse. 

The  results  obtained  have  been  on  the  whole  excellent. 
A  t3'pical  case  is  reported  by  ^fr.  Page  of  Newcastle  (Brit. 
Med.  Journ.,  Dec.  10,  1887).  Mr.  Page  has  treated  other  cases 
since  this  date  with  equal  success. 

There  is  nothing  to  commend  the  operation  of  removing 
the  condyle  through  the  mouth  without  external  wound. 


753 


§art   YIL 
TE^WTOMY, 

INCLUDING  OPERATIONS  FOR  THE  DIVISION   OF  CONTRACTED 
MUSCLES,   LIGAMENTS,    AND   FASCIA. 

The  term  tenotomy  is  applied  very  obviously  to  the  cutting 
of  a  tendon,  and  myotomy  to  the  division  of  a  muscle. 

The  term  myo-tenotomy  has  been  applied  to  such 
operations  as  involve  the  cutting  of  both  muscular  and 
tendinous  fibres,  as  in  the  usual  section  of  the  sterno-mastoid 
muscle.  Mr.  K.  W.  Parker  has  given  to  his  operation  for 
dividing  certain  hgamentous  structures  in  club-foot  the  name 
of  "  S3nidesmotomy,"  i.e.,  a  cutting  of  hgament.  Aponeuro- 
tomy  has  been  associated  with  the  division  of  bands  of  con- 
tracted fascia. 

The  first  operation  of  tenotomy  is  ascribed  to  Roonhuysen 
of  Amsterdam,  who  divided  the  sterno-mastoid  tendon  in 
1670  ("  Historische  Heilcuren,"  Xlimberg,  1674,  ob.  xxii). 
All  the  earher  operations  were  carried  out  by  the  open 
method.  The  tendon  was  exposed  by  reflecting  the  skin,  and 
was  then  divided. 

Later,  we  find  that  a  knife  was  introduced  beneath  such  a 
tendon  as  the  tendo  Achillis,  and  that  that  structure  was 
divided  simultaneously  with  the  skin  that  covered  it. 

Delpech  laid  down  the  principles  of  the  subcutaneous 
method  of  operating  as  practised  at  the  present  day 
(Chirurgie  Clinique  de  Montjpellier,  1823,  t.  L,  page  184). 

It  is  remarkable,  however,  that  he  did  not  carry  out  his 
principles,  for  in  dividing  the  Achilles  tendon  he  made  a  cut 
on  each  side  of  the  tendon  one  inch  in  length. 

Astley  Cooper  ("On  Dislocations  and  Fractures,"  6th  ed., 
1829,  page  476)  employed  the  subcutaneous  method  for 
dealing  with  contracted  fasciae  in  the  hand. 


754  OPERATIVE    SURGERY. 

To  Stromejer  is  due  tlie  main  credit  of  introducing  the 
subcutaneous  method  into  practice.  He  first  apphed  it  to  the 
Achilles  tendon  in  1831. 

The  history  of  this  subject  is  admirably  dealt  with  in 
Dr.  Little's  "Treatise  on  Club-foot"  (London,  1839). 

GENERAL   CONSIDERATIONS. 

1.  The  Subcutaneous  Method.  —  The  object  of  this 
method  is  to  divide  the  tendon  with  the  least  disturbance  of 
the  surrounding  parts,  and  mth  the  smallest  possible  division 
of  the  skia.  Air  is  not  admitted  to  the  deep  wound ;  the  risk 
of  sepsis  is  thus  minimised,  and  the  surface  puncture  heals 
readily  and  surely.  Before  the  introduction  of  the  antiseptic 
method  of  treating  wounds,  the  subcutaneous  operation  was  all- 
essentiaL  At  the  present  time  it  should  be  carried  out  whenever 
convenient  and  possible.  It  must  be  remembered,  however,  that 
in  the  subcutaneous  operation  the  surgeon  is  cutting  a  little  in 
the  dark,  and  in  dividing  such  tendons  as  that  of  the  tibialis 
posticus  and  the  sterno-mastoid  considerable  damage  has 
been  inflicted  by  the  movements  of  the  invisible  blade 
beneath  the  skin.  This  perhaps  more  especially  applies  to  fat 
infants  and  to  examples  of  extreme  deformity. 

Since  the  conditions  which  rendered  the  subcutaneous 
method  essential  are  now  no  longer  all-important,  it  is  well 
not  to  adhere  too  bhndly  to  the  principle  ;  and  in  any  case  in 
which  the  tendon  is  difficult  to  discover,  and  in  which  its 
relations  with  nerves  and  vessels  are  complex  and  intimate,  it 
is  better  to  return  to  the  open  method  of  the  older  surgeons, 
and  to  expose  the  area  of  the  operation  by  a  free  incision. 

With  these  exceptions  the  subcutaneous  operation  should 
be  always  adopted. 

There  is  no  need  to  draw  the  skin  aside  before  making  the 
puncture  in  order  that  the  wound  in  the  skin  may  not  cor- 
respond to  the  wound  of  the  deeper  parts  when  the  operation 
is  complete.  Such  a  method  is  embarrassing,  and  adds  a 
needless  difficulty  to  a  simple  procedure.  The  skin,  moreover, 
may  be  unnecessarily  cut  by  the  knife  against  which  it  is 
strained. 

It  must  not  be  assumed  that  because  the  subcutaneous 


TENOTOMY.  755 

method  is  employed,  no  care  need  be  taken  to  ensure  an 
aseptic  environment  for  the  little  operation. 

The  parts  should  be  well  scrubbed  with  some  carbolic 
solution ;  the  tenotomes  should  be  absolutely  clean,  and 
should  be  placed  in  a  solution  of  carbolic  acid  before  being 
used. 

2.  The  Use  of  the  Tenotome. — The  tendon  or  band  of 
fascia  to  be  divided  is  usually  unduly  prominent,  or  can  be 
readily  made  distinct.  The  tendon  should,  if  possible,  be  so 
cut  as  to  avoid  opening  a  synovial  sheath. 

The  tenotome  should  be  lightly  held,  as  one  would  hold  a  pen. 
The  sharp-pointed  instrument  is  carefully  introduced  close  to 
the  tendon,  and  makes  a  way  for  the  blunt-pointed  instrument. 
It  is  essential  that  it  should  make  an  ample  passage  for  the 
blunt-pointed  tenotome,  and  therefore  the  cutting-point  may 
need  to  be  moved  freely  to  and  fro  in  the  region  of  the  tendon. 
If  this  be  not  done,  the  blunt  tenotome  may  have  to  be  forced 
to  its  destination  through  tissues  that  have  been  merely 
punctured. 

The  sharp  tenotome  is  withdrawn,  and  the  blunt  instru- 
ment introduced,  with  the  blade  "  flat " — that  is,  in  a  line  with 
the  line  of  the  skin  wound. 

The  instrument  should  throughout  be  kept  close  to  the 
tendon  or  band  to  be  divided,  and  care  must  be  taken  to 
avoid  damage  to  adjacent  vessels  or  nerves.  The  breaking  of 
the  point  of  the  tenotome  against  the  bone  is  not  a  very 
infrequent  accident. 

As  the  tenotomes  are  beinof  introduced  the  tendon  should 
be  only  stretched  to  such  an  extent  as  is  necessary  to  render 
its  position  distinct.  It  needs  to  be  stretched  to  its  utmost 
when  its  fibres  are  being  divided,  but  this  tension  may  be  a 
little  relaxed  as  the  last  strands  are  being  cut.  The  tendon  is 
divided  with  a  sawing  movement ;  it  cuts  with  a  creaking 
sound  or  sensation,  and  yields  finally  with  a  snap.  A 
common  source  of  failure  after  this  operation  is  due  to  an 
incomplete  division  of  the  tendon. 

The  left  forefinger  should  be  kept  upon  the  skin  at  the  site 
of  the  operation,  in  order  that  the  movements  of  the  teno- 
tomes beneath  the  integument  may  be  followed  and  guarded. 

It  is  not  usually  desirable  to  do  the  whole  operation  with 
w  w  2 


766  OPERATIVE    SUEGEBY. 

the  sharp  tenotome  onl}'.  In  dealing  with  certain  bands  of 
contracted  fascia  and  some  few  tendons,  the  one  instrument 
may  be  employed.  But  in  most  cases,  especially  when  the 
tendon  is  surrounded  by  tissues  of  importance,  the  two  instru- 
ments should  be  made  use  of — the  sharp-pointed  tenotome  to 
divide  the  skin  and  the  fascia  about  the  tendon,  and  the  blunt- 
pointed  instrument  to  sever  the  tendon  itself. 

This  operation  d  deux  temps  involves  a  httle  more  time, 
and  is  a  little  less  brilliant,  but  it  is  safer  and  more 
satisfactory. 

3.  The  After-treatment. — The  operation  is  practically 
bloodless,  and  the  only  dressing  needed  is  a  pledget  of  avooI 
dusted  with  iodoform.  In  forty-eight  hours  the  Httle  puncture 
may  be  considered  to  be  healed. 

The  only  factor  in  the  after-treatment  which  has  been  the 
subject  of  much  difference  of  opinion  has  to  do  with  the 
adjustment  of  the  hmb  after  the  tenotomy. 

The  discussion  upon  this  subject  has  been  practically 
hmited  to  the  treatment  of  cases  of  club-foot,  and  the  ques- 
tion has  been — Should  the  foot  be  immediately  restored  to  its 
normal  position  after  tenotomy,  or  should  it  be  put  up  for  a 
while  in  the  deformed  or  original  position  ? 

The  following  book  and  papers  bearing  upon  the  matter 
may  be  consulted : — "  Congenital  Club-Foot,  its  Nature  and 
Treatment,"  by  R  W.  Parker,  1887  ;  and  articles  by  Dr.  R. 
Sayre  (Alabama  Med.  and  Surg.  Journal,  July,  1886),  Mr. 
Howard  Marsh  {Lancet,  Feb.  18th,  1888),  Discussion  on  the 
Operative  Treatment  of  Club-Foot  {British  Medical  Jouriml, 
Oct.  27th,  1888),  and  a  paper  by  Mr.  Walsham  {Lancet,  May 
19th,  1888).  Mr.  Walsham  gives  the  following  general  review 
of  the  subject,  and  with  his  conclusions  my  own  experience 
leads  me  to  agree : — "  As  regards  the  restoration  of  the 
foot  after  tenotomy,  there  may  be  said  to  be  three  chief 
methods  in  vogue.  (1)  The  slow,  in  which  the  ends  of  the 
tendon  are  placed  in  contact  for  a  few  days,  and  after  union 
has  taken  place  the  new  material  uniting  the  ends  is  slowly 
stretched.  (2)  The  rapid,  in  which  a  slight  interval  is  left 
between  the  ends  of  the  tendon,  and  the  foot  placed  in  plaster 
of  Paris  for  a  week,  after  which  the  plaster  is  reapplied  twice 
or  thrice,  at  intervals  of  about  a  week,  the  foot  on  each  occasion 


TENOTOMY.  757 

being  forced  into  a  better  j)osition."  (This  method  is  advo- 
cated by  Mr.  Howard  jMarsh.)  "And  (3)  the  immediate 
method,  in  which  a  considerable  space  is  left  between  the  ends 
of  the  divided  tendon,  the  foot  being  at  once  secured  in 
the  normal  position  in  plaster  of  Paris."  Mr.  Walsham  having 
pointed  out  that  the  rapid  method  is  a  great  improvement 
upon  the  slow,  and  that  the  immediate  method  is  a  still 
further  advance  upon  the  rapid,  concludes  as  follows : — "  The 
advantages  of  the  iminediate  method,  as  well  as  of  the 
rapid  method  over  the  slow,  are — (xreat  saving  of  time,  and 
the  doing  away  with  the  necessity  of  an  expensive  extension 
apparatus.  The  disadvantages  attending  the  rapid,  but 
which  do  not  apply  to  the  iminediate,  are — That  considerable 
pain  is  often  caused  by  the  force  which  has  to  be  employed  in 
stretching  the  uniting  material  at  each  changing  of  the  plaster, 
and  that  in  severe  cases  the  reparative  material  cannot 
always  be  stretched  sufficiently  to  overcome  the  deformity, 
and  it  is  occasionally  necessary  to  re-divide  the  tendon."  It 
has  been  clearly  shown  that  in  both  the  rapid  and  the  imme- 
diate methods  there  is  no  failure  in  the  uniting  material  which 
joins  the  ends  of  the  divided  tendon,  nor  has  the  uniting  band 
remained  weak  or  elongated.  The  possibility  of  this  occurrence 
has  been  the  main  argument  in  favour  of  the  slow  method. 

The  above  remarks  refer  for  the  most  part  to  infants  and 
children.  In  dealing  with  large  tendons — such  as  the  tendo 
Achillis  in  adults — it  is  desirable  still  to  adhere  to  the  slow 
method,  to  allow  the  limb  to  remain  for  some  days  or  a  week 
in  the  deformed  attitude,  and  then  to  gradually  correct  the 
false  position.  In  not  a  few  instances  in  which  the  limb  has 
been  adjusted  in  what  may  be  termed  the  normal  position, 
after  the  accidental  rupture  or  division  of  a  large  tendon  in  an 
adult,  the  union  between  the  separated  ends  has  been  feeble 
and  inefficient. 

4.  The  Instruments  Used.  —  Sharp  and  blunt-pointed 
tenotomes,  with  straight  blades,  are  the  only  instruments 
needed.  These  knives  must  vary,  both  in  size  and  strength, 
according  to  the  proportions  of  the  structure  requiring  divi- 
sion. There- should  be  a  mark  upon  the  handle  to  indicate 
the  position  of  the  cutting  edge  when  the  blade  is  out 
of  view. 


758  OPERATIVE    SUEGEUY. 

The  sickle-shaped  tenotomy  knife  is  seldom  used  in  Great 
Britain,  and  figures  in  but  few  English  catalogues. 

PARTICULAR   OPERATIONS. 

Tibialis  Anticus  Tendon. — This  tendon  descends  through 
the  innermost  sheath  of  the  annular  ligament,  and  crossing 
the  ankle-joint,  astragalus,  scaphoid,  and  internal  cuneiform 
bones,  is  inserted  into  the  inner  side  of  the  last-named  bone 
and  the  base  of  the  lirst  metatarsal  bone.  The  synovial 
sheath  which  accompanies  it  extends  upwards  for  some 
distance  above  the  level  of  the  malleoli.  A  small  bursa  lies 
beneath  the  tendon  as  it  crosses  the  cuneiform  bone. 

This  tendon  is  usually  divided  as  it  is  crossing  the 
scaphoid  bone,  and  consequently  about  one  inch  above  its 
insertion.  At  this  point  it  should  be  free  of  its  synovial 
sheath.  The  dorsahs  pedis  vessels  lie  to  the  outer  side,  with 
the  extensor  proprius  pollicis  tendon  intervening. 

In  cases  of  congenital  club-foot  the  tendon  is  displaced 
inwards,  and  is  nearer  to  the  malleolus.  It  is  readily  made 
prominent. 

Operation. — The  surgeon  stands  on  the  outer  side  of  the 
limb  in  the  case  of  either  tendon.  The  assistant,  who  takes 
his  place  opposite  to  him,  grasps  the  foot  with  one  hand  and 
the  leg  with  the  other.  The  foot  is  held  in  the  position  of  ex- 
tension and  abduction,  and  the  tendon  is  defined.  The  sharp 
*;enotome  is  then  entered  vertically  upon  the  outer  side  of  the 
tendon,  and  is  pushed  do-wnwards  until  it  has  reached  a  point 
below  the  level  of  the  tendon.  The  operator's  left  forefinger 
is  kept  over  the  skin  upon  the  plantar  side  of  the  tendon  as  a 
guard  upon  the  instrument.  The  tendon  is  put  on  the  stretch. 
The  sharp  tenotome  is  Avithdrawn,  and  the  blunt-pointed  one 
inserted  in  its  place.  After  it  has  reached  the  depth  acquired 
by  the  first  instrument  (whose  tract  it  exactly  follows)  the  foot 
is  relaxed,  and  the  blunt  point  is  pushed  nearly  horizontally 
1  )eneath  the  tendon,  and  may  be  felt  on  its  plantar  side.  The 
t(!ndon  is  once  more  put  upon  the  stretch,  and  is  divided  by 
cutting  upwards  towards  the  skin.  The  left  forefinger  lies 
upon  the  skin  over  the  edge  of  the  knife,  and  forms  a  certain 
check  to  its  movement.  The  surgeon  cuts,  indeed,  upon  the 
left  finger,  the  skin  intervening. 


TENOTOMY.  759 

Tibialis  Posticus  Tendon. — The  tendon  becomes  free  of 
muscular  fibres  about  the  level  of  the  tibio-fibular  articulation. 
It  grooves  the  back  of  the  inner  malleolus,  running  in  the 
innermost  compartment  of  the  internal  annular  ligament. 
Behind  the  malleolus  it  is  invested  in  a  synovial  sheath. 
The  flexor  longus  digitornm  tendon  lies  next  to  it  (to  its  outer 
side),  and  is  provided  with  a  separate  synovial  sheath.  Ex- 
ternal to  this  latter  tendon  run  the  posterior  tibial  vessels. 

The  tendon  is  usually  divided  above  the  point  of  com- 
mencement of  its  synovial  sheath,  i.e.,  about  the  level  of  the 
base  of  the  malleolus,  and  therefore  above  the  inner  annular 
ligament.  The  tendon  is  here  easily  approached,  and  is  at 
some  distance  from  the  blood-vessels.  Weis  and  Velpeau 
recommended  division  of  the  tendon  at  its  insertion  into  the 
scaphoid  bone.  No  advantage  has  been  claimed  for  this 
method,  and  it  is  inapplicable  to  infants. 

The  tendon  has  been  severed  a  little  way  below  the  tip  of 
the  malleokis.  The  selection  of  this  point  is  to  be  con- 
demned. The  S3Tiovial  sheath  must  be  opened ;  the  tendon 
lies  close  to  the  ankle-joint,  and  is  in  more  intimate  relation 
with  the  accompanying  blood-vessels  than  it  is  at  the  spot 
usually  selected. 

Operation. — The  surgeon  stands  to  the  outer  side  of  the 
limb  in  the  case  of  either  tendon.  The  assistant  faces  him, 
and  grasps  the  foot  with  one  hand,  and  the  leg  with  the  other. 

The  position  of  the  tendon  is  made  out,  and  the  foot  is 
held  a  little  extended  and  abducted,  and  is  so  turned  as  to 
lie  upon  its  outer  side. 

The  surgeon  seeks  for  that  point  on  the  inner  surface  of 
the  tibia  where  the  malleolus  joins  the  shaft  of  the  bone. 
He  reaches  this  point  by  following  the  posterior  margin  of 
the  malleolus.  The  spot  in  question  will  be  about  a  finger's 
breadth  above  the  tip  of  the  malleolus  in  the  infant,  and 
about  one  and  a  half  to  two  inches  above  that  process  in 
the  adult.  It  is  really  on  the  shaft,  and  is  above  Avliat  would 
be  called,  anatomicall}',  the  base  of  the  malleolus. 

The  surgeon  fixes  his  left  thumb-nail  upon  the  margin 
of  the  bone,  and  enters  the  sharp  tenotome  vertically  betAveen 
the  tibia  and  the  tendon,  using  the  nail  as  a  guide.  The 
instrument  should  be  kept  as  near  as  possible  to  the  bone. 


760  OPERATIVE    8UBGEBY. 

If  properly  inserted  it  will  remain,  as  Mr.  Heath  has  pointed 
out,  fixed,  without  any  support  of  the  hand.  The  tendon 
should  not  be  too  tightly  stretched  at  this  stage  of  the 
operation. 

The  fascia  about  the  tendon  should  be  freely  divided  by 
moving  the  point  of  the  instrument  to  and  fro,  but  without 
enlarging  the  skin-wound.  Unless  this  be  done,  a  proper 
way  may  not  be  made  for  the  blunt-pointed  instrument. 

As  the  sharp  tenotome  is  withdrawn  the  blunt  one  is 
mtroduced — the  edge  is  turned  towards  the  tendon,  the 
tendon  is  put  upon  the  stretch  and  is  divided  by  cutting 
from  the  bone.  The  left  forefinger,  placed  over  the  site  of 
the  tendon,  forms  a  guide  and  a  guard.  The  tendon  of  the 
llexor  longus  digitorum  is  usually  cut  at  the  same  time,  and 
is  often  divided  unconsciously. 

The  assistant  should  judiciously  relax  the  strain  upon 
the  tendon  as  its  fibres  are  divided. 

It  is  obvious  that  if  little  care  be  taken  the  knife  may 
cut  through  both  the  tendons,  as  through  tightly-drawn  cords, 
and  may  wound  the  main  artery  beyond. 

If  the  blood-vessels  should  be  divided,  well-adjusted 
pressure  must  be  at  once  applied  to  the  spot. 

Singularly  little  trouble  appears  to  have  supervened  in 
examples  of  this  accident. 

The  position  of  the  tendon  may  be  difilcult  to  make  out 
in  a  case  of  talipes  varus  in  an  infant,  and  in  connection 
with  this  point  the  following  observations  by  Dr.  Little  may 
be  quoted  : — "  When  the  surgeon  cannot  feel  the  tendon,  it 
is  practically  quite  sufiicient  to  make  out  the  inner  edge 
of  the  tibia,  about  a  finger's  -  breadth  above  the  lower  end 
of  the  inner  malleolus  ;  or  should  there  be  any  difficulty  in 
defining  this  ridge  of  bone  in  consequence  of  the  fatness  of 
the  limb,  the  careful  insertion  of  the  laiife  exactly  midway 
between  the  anterior  and  posterior  borders  of  the  leg,  on 
its  inner  aspect,  will  be  an  exact  guide  to  the  position  of 
the  tendon,  not  forgetting,  as  anatomy  teaches  us,  that  an 
incision  made  a  little  in  front  of  this  line  might  wound 
the  internal  saphenous  vein  and  nerve  ;  and  if  made  behind, 
would  run  the  risk  of  dividing  the  flexor  communis  digit- 
orum, instead  of  the  tibialis   posticus  ;  or   the   knife   might 


DIVISION    OF  PLANTAR    FASCIA.  761 

even  pass  posterior  to  the  former  tendon,  and,  if  canned 
deep  enough,  might  wound  the  artery  and  nerve  without 
touching  any  tendon  whatever." 

Plantar  Fascia,  Muscles  and  Ligaments  of  the  Sole  of 
the  Foot. 

These  operations  are  concerned  principally  with  cases  of 
congenital  talipes  varus,  and  notably  with  such  examples  as 
are  associated  with  considerable  incurving  of  the  sole.  In 
the  practice  of  some  surgeons  these  plantar  operations  con- 
stitute the  sole  operative  treatment  of  club-foot,  if  exception 
be  made  of  tenotomy  of  the  tendo  Achillis. 

The  plantar  fascia  consists  of  a  central  and  of  two  lateral 
portions.  The  central  part — which  was  originally  the  plantar 
portion  of  the  plantaris  tendon — is  the  segment  dealt  with. 
Its  great  density  is  well  known.  It  splits  up  into  slips  for 
the  toes  in  front,  while  behind  it  becomes  much  narrowed, 
and  is  attached  to  the  inner  tubercle  of  the  os  calcis. 

It  is  closely  connected  with  the  flexor  brevis  digitorum 
muscle,  which  it  covers.  The  ultimate  fibres  of  this  fascia 
are  intimately  associated  with  the  skin. 

Simple  Division  of  the  Plantar  Fascia. — The  sole  of  the 
foot  is  well  exposed,  and  the  limb  is  firmly  held  by  an  assist- 
ant. The  resisting  bands  of  the  plantar  fascia  are  made 
out  by  putting  the  parts  upon  the  stretch.  The  part  usually 
divided  will  be  a  little  in  front  of  the  attachment  of  the 
fascia  to  the  os  calcis,  or  close  to  the  transverse  markino's 
near  the  heel,  which  are  conspicuous  in  severe  talipes  varus 
(Fig.  220). 

A  very  fine,  narrow,  and  short-bladed  tenotome  is  em- 
ployed, and  is  introduced  between  the  fascia  and  the  skin. 
The  edge  having  been  turned  towards  the  resisting  band,  it 
is  divided  by  cutting  towards  the  depths  of  the  sole,  i.e., 
away  from  the  skin. 

The  depth  to  which  the  cutting  is  continued  must  depend 
upon  the  thickness  of  the  contracted  tissue. 

The  surgeon  would  naturally  avoid  points  where  the  fascia 
has  become  closely  attached  to  the  skin. 

As  a  rule  the  contracted  tissue  will  need  to  be  severed 
at  several  points,  and  these  multiple  punctures  are  more 
efficacious  than  one  sinsfle  incision. 


762 


OPERATIVE    SURGERY. 


Buchanan's  Operation. — The  following  method  is  adopted 
b}'  Dr.  Buchanan  of  Glasgow.  The  proceeding  is  applied  to 
cases  of  talipes  varus   in  children,  "  in  which  the  abnormal 

position  of  the  bones  is  maintained 
by  such  a  degree  of  tension  and 
rigidity  of  the  soft  parts  as  renders 
reduction  by  hand  practically  im- 
possible without  the  division  of  the 
offending  structures." 

The  following  is  Dr.  Buchanan's 
description  : — "  The  sections  I  find 
it  usually  necessary  to  make  are  first, 
always,  the  tendo  Achillis,  to  relieve 
the  equinus  part.  I  never  divide 
the  tibialis  posticus  behind  the  ankle, 
being  satisfied  that  such  a  muscle, 
as  well  as  all  the  other  muscles 
arising  in  the  leg  and  inserted  into 
the  foot,  can  be  stretched  by  suffi- 
cient manipulation  ;  but,  secondly, 
the  structures  which  do  maintain  the 
incurved  form  of  the  foot,  the  plantar 
fascia  and  the  muscular  substance 
attached  to  it — namely,  the  abductor 
pollicis  and  the  adjoining  half  of  the 
flexor  brevis  digitorum  ;  probably  also  the  part  of  the  deep  plan- 
tar ligament  which  binds  the  astragalus  to  the  scaphoid  and 
other  bones  distal  to  it.  In  order  to  divide  these,  which  I  con- 
sider the  most  resisting  tissues,  I  enter  a  tenotomy  knife  at  the 
inner  edge  of  the  foot  opposite  the  tuberosity  of  the  scaphoid 
bone,  pass  it  flatly  superficial  to  the  plantar  fascia  till  the 
point  reaches  the  middle  of  the  sole  of  the  foot ;  I  now  turn 
the  edge  of  the  knife  vertical,  elevate  the  handle  to  depress 
tlie  point,  and  cut  through  and  through  the  pkantar  fascia 
and  the  muscles  underneath  it  till  the  point  is  over  the 
articulation  between  the  head  of  the  astragalus  and  cup  of 
the  scaphoid  bone.  Here  the  point  is  made  to  cut  through 
the  tendon  of  the  tibialis  posticus  proximal  to  its  insertion 
into  the  scaphoid  tuberosity,  and  by  the  same  cut  the  deep 
ligamentous   Hbres  are  clividod,  thus   completely  freeing  the 


Fig.  220. — SOLE  OF  THE  FOOT 
IN  TALIPES  VAEUS,  TO  SHOW 
THE     CEEASES     ON    THE   SKIN. 

{Modified from  11.  W.  Parker. ) 


SYNDEiSMOTOMY.  763 

astragalo-scaphoid  ball-and-socket  joint,  which  is  really  the 
one  on  which  the  incurvation  of  the  foot  hinges.  In  doing 
this  the  external  plantar  nerve  is  wounded,  but  in  my 
experience  it  always  unites — at  least,  never  loses  its  function. 
So  also  the  internal  plantar  artery  is  divided  ;  but  it  is  a 
small  vessel,  and  never  ^ives  trouble,  tlic  foot  being  nourished 
by  the  deep  plantar  arch  from  the  external  plantar  artery. 
In  my  own  experience,  involving  a  large  number  of  opera- 
tions, and  in  the  practice  of  others  who  adopt  ni}'  operation, 
including  most  of  those  who  have  been  educated  in  this 
university  and  others  who  have  read  my  papers,  not  an 
accident  has  ever  occurred  from  this  somewhat  heroic 
incision  ;  but  it  has  been  attended  with  most  fortunate 
results  "  {Brit.  Med.  Journ.,  October  27,  1888).  This  opera- 
tion is,  as  the  author  observes,  heroic,  and  will  probably  not 
commend  itself  to  cautious  surgeons. 

Parkers  Operation — Syndesmotomy. — In  cases  of  con- 
genital talipes  varus  in  children  Mr.  R.  W.  Parker  is  disposed 
to  attach  much  more  importance  to  the  division  of  ligaments 
and  the  plantar  fascia  than  to  pure  tenotomy.  "With  the 
exception  of  the  tendo  Achillis,"  he  writes,  "  I  think  tenotomy 
in  club-foot  might  be  almost  abandoned  as  a  separate  and 
independent  operation.  The  two  other  tendons  most 
frequently  cut  are  the  tibials,  anterior  and  posterior.  I 
believe,  if  it  is  necessary  to  divide  them,  that  it  should  be 
done  simultaneously  with  the  ligaments  Avith  which  they 
are  closely  associated,  and  this  is  most  advantageously 
done  at  or  near  their  insertions,  where  they  spread  out  as 
fibrous  expansions  closely  blended  with  the  capsular  liga- 
ments connecting  the  head  of  the  astragalus  with  the 
scaphoid,  the  scaphoid  with  the  internal  cuneiform,  and  this 
latter  with  the  base  of  the  first  metatarsal  bone,  all  these 
joints  being  much  approximated  by  the  incurvation  of  the 
inner  border  of  the  foot."  This  ligamentous  tissue  Mr. 
Parker  calls  the  astragalo-scaphoid  capsule,  and  he  en- 
deavours to  combine  a  division  of  it  with  simultaneous 
division  of  the  two  tibial  tendons.  He  terms  the  operation 
"  Syndesmotomy." 

The  site  chosen  for  this  combined  section  of  ligaments  and 
tendons  is  a  spot  a  little  below  and  in  front  of  the  tip  of  the 


764  OPERATIVE    SUEGEBY. 

inner  malleolus,  over  the  site  of  the  astragalo-scaphoid  joint, 
and  in  the  situation  of  the  transverse  mark  near  the  heel 
which  is  to  be  observed  in  severe  tahpes  (Fig.  220).  Two 
tenotomes  are  needed — an  ordinary  sharp-pointed  tenotome, 
and  a  curved  one  of  sickle  shape  with  a  cutting  edge  about 
half  an  inch  in  length. 

The  Operation. — The  foot  is  so  placed  as  to  fully  expose 
its  inner  border,  and  is  firmly  held;  the  position  of  the 
tendons  and  the  arteries  is  made  out  so  far  as  is  possible. 

At  the  spot  above  mentioned  the  sharp  tenotome  is 
entered.  It  should  enter  in  front  of  the  bifurcation  of 
the  posterior  tibial  artery,  and  behind  the  posterior  tibial 
tendon.  The  knife  is  pushed  forwards  and  outwards 
under  the  skm  until  a  spot  on  the  dorsum  is  reached 
just  mternal  to  the  anterior  tibial  artery.  The  sharp 
instrument,  which  has  made  a  tract  merely,  is  withdrawn. 
The  curved  tenotome  is  now  inserted  flat-wise  under  the  skin, 
and  follows  the  subcutaneous  course  already  made  until  its 
point  can  be  felt  over  the  tibialis  anticus  tendon.  The  edge  is 
turned  towards  the  tendon,  and  is  made  to  cut  to  the  bone. 
It  severs  the  tendon,  and  as  it  is  withdrawn  is  made  in  like 
manner  to  cut  the  dense  ligamentous  tissue  already  described. 
Just  as  it  is  being  withdrawn  it  is  made  to  sever  the  tendon 
of  the  tibialis  posticus. 

During  the  introduction  of  the  instruments  the  foot  is 
relaxed.  During  the  cutting  of  the  tissues  it  is  put  upon  the 
stretch,  and  the  yielding  of  the  divided  ligaments  and  tendons 
is  made  very  evident. 

Although  the  internal  saphenous  vein  must  lie  across  the 
incision,  the  bleeding  is  usually  quite  insignificant. 

This  operation  has  been  extensively  adopted,  and  has  been 
attended  with  a  considerable  degree  of  success.  It  has  an 
advantage  over  the  procedure  advised  by  Dr.  Buchanan  in  so 
for  as  it  is  more  precise  and  less  heroic.  Now  that  the  treat- 
ment of  wounds  is  conducted  upon  precise  and  successful 
principles,  there  is  no  reason  why  the  subcutaneous  method 
should  be  adhered  to  in  this  or  allied  operations. 

The  parts  to  be  severed  might  be  exposed  by  turning  up  a 
small  flap  of  skin,  which  could  be  replaced  and  secured  by 
sutures  after  the  division  had  beon  completed 


TENOIOMY.  765 

Tendo  Achillis. — This  very  powerful  tendon  measures  in 
the  adult  soiiie  four  and  a  half  inches  in  length,  three-quarters 
of  an  inch  in  breadth,  and  a  quarter  of  an  inch  in  thick- 
ness. 

It  is  best  divided  at  its  narrowest  part,  i.e.,  about  one  inch 
above  its  insertion. 

Operation. — The  patient  may  lie  upon  the  back,  with  the 
body  a  little  rolled  over  towards  the  afi'ected  side. 

The  foot  is  so  turned  as  to  he  entirely  upon  its  outer 
side,  and  a  small  cushion  placed  beneath  the  lower  25art  of  the 
leg  will  carry  the  heel  off  the  table. 

The  surgeon  stands  to  the  outer  side  of  the  limb,  in  the 
case  of  both  the  right  and  the  left  foot. 

An  assistant  standing  by  his  side  holds  the  foot.  Another 
assistant  may  steady  the  leg. 

The  tendon  having  been  defined  is  rendered  a  httle  tense, 
but  is  not  fully  stretched.  The  sharp  tenotome  is  entered 
vertically  at  the  inner  margin  of  the  tendon,  and  is  pushed 
downwards — in  the  present  position  of  the  foot — until  it  has 
reached  the  outer  side  of  the  tendon,  where  its  point  can  be 
indistinctly  felt.  The  sharp-pointed  instrument  is  now 
replaced  by  the  blunt,  which  follows  the  tract  already  made 
until  its  pomt  can  in  turn  be  detected  through  the  skin. 
The  instrument  must  be  kept  very  close  to  the  tendon.  The 
tendon  is  now  put  well  upon  the  stretch,  and  the  cutting 
edge  having  been  turned  towards  the  surface,  the  tense  cord  is 
divided  with  a  sawing  movement,  the  left  forefinger  resting 
upon  the  skin  over  the  site  of  the  operation. 

The  divided  ends  separate  with  a  snap,  and  unless  care  be 
taken  just  at  the  time  when  the  tendon  gives  way,  the 
integuments  covering  it  may  be  divided  by  the  suddenl}-- 
liberated  knife. 

The  short  saphenous  vein  lies  very  near,  and  usually  just 
anterior  to,  the  outer  margin  of  the  tendoiL  The  nerve  which 
accompanies  it  is  as  a  rule  anterior  to  the  vein  at  a  pomt  one 
inch  above  the  heeL  The  only  structure  in  near  relation  to 
the  inner  border  of  the  tendon  is  the  unimportant  calcaneo- 
plantar  nerve. 

Notliing  but  the  grossest  clumsiness  could  place  the 
posterior  tibial  vessels  in  danger. 


766  OPERATIVE    SURGEBY. 

The  beginner  is  apt  to  fall  into  two  errors.  In  the  first 
place,  he  does  not  push  the  knife  far  enough  towards  the  outer 
side,  and  as  a  result  leaves  the  most  external  fibres  of  the 
tendon  undivided  ;  or,  on  the  other  hand,  in  his  anxiety  to 
keep  close  to  the  tendon,  he  may  thrust  the  sharp  instrument 
through  its  deeper  fibres,  which  at  the  completion  of  the 
operation  are  left  uncut. 

Some  surgeons  let  the  patient  lie  upon  the  face,  with  the 
foot  overhanging  the  end  of  the  table.  They  sit  to  operate, 
and  having  introduced  the  tenotome  upon  either  the  inner  or 
the  outer  side,  cut  upwards. 

Peroneus  Longus  and  Brevis. — The  tendons  of  the  two 
peronei  pass  down  in  the  hollow  behind  the  outer  malleolus, 
and  form  a  groove  upon  that  process  of  bone.  Behind  the 
malleolus  they  are  contained  in  the  same  fibrous  and  synovial 
sheath  beneath  the  annular  Hgament.  The  tendon  of  the 
peroneus  brevis  is  placed  next  to  the  fibula  as  it  turns  below 
that  bone.  The  tendon  of  the  peroneus  longus  muscle  is  the 
more  superficial  of  the  two.  They  are  both  very  close  to  the 
bone.  On  the  outer  side  of  the  os  calcis  the  tendons  separate 
and  acquire  separate  synovial  sheaths. 

Operation. — Both  tendons  are  usually  divided  together  at 
a  point  about  one  inch  and  a  half  above  the  tip  of  the 
malleolus.  The  section  if  made  hero  will  be  above  the 
synovial  sheath.  The  patient  is  rolled  over  upon  the  sound 
side,  and  the  foot  is  so  placed  that  it  rests  upon  its  inner 
surface,  with  the  outer  aspect  uppermost.  A  firm  cushion  is 
placed  under  the  lower  part  of  the  leg,  and  the  foot  is  ex- 
tended over  it.  An  assistant  steadies  the  foot  and  leg.  The 
tenotome  is  introduced  at  the  spot  mentioned,  is  inserted  close 
to  the  fibula,  between  the  bone  and  the  tendons,  and  has  to  be 
carried  a  little  obhquely.  The  peronei  are  rendered  slack 
when  the  instrument  is  being  introduced. 

When  the  blunt-pointed  tenotome  is  in  position,  the  foot 
should  be  so  held  as  to  put  the  tendons  upon  the  stretch,  and 
they  are  divided  by  cutting  from  the  bone,  the  skin  being 
guarded  in  the  usual  way. 

The  short  saphenous  vein  and  nerve  are  posterior  to  the 
tendons  at  the  place  of  election,  and  will  not  be  endangered 
if  the  tenotome  be  kept  close  I.0  the  bone.     The  vein  may  be 


TENOTOMY.  767 

damaged  if  the  whole  operation  be  carried  out  with  a  sharp- 
pointed  instrument. 

If  it  be  necessary  to  divide  one  tendon  and  not  the  other, 
the  two  structures  should  be  exposed  throuf^h  a  small  incision, 
and  the  selected  tendon  drawn  forwards  and  divided.  The 
elaborate  methods  given  for  the  subcutaneous  division  of  a 
single  tendon  behind  the  malleolus  are  of  no  practical  value. 

If  one  or  both  of  the  peronei  be  divided  below  the 
malleolus,  it  is  as  well  to  expose  the  tendons  through  a  small 
incision,  rather  than  cut  blindly  with  a  hidden  knife.  The 
peroneus  brevis  in  the  foot  lies  above  the  peroneus  longus. 

Extensor  Longus  Digitorum  and  Peroneus  Tertius. — 
The  extensor  tendons  can  be  conveniently  divided  in  front 
of  or  just  below  the  ankle.  In  the  latter  situation  there  is 
greater  risk  of  injuring  the  dorsalis  pedis  artery. 

The  patient  lies  upon  the  back,  with  the  foot  extended. 
The  surgeon  places  himself  to  the  inner  side  of  the  Hmb.  An 
assistant  grasps  the  leg  and  foot.  The  tenotome  is  entered 
upon  the  inner  side,  between  the  tendon  of  the  extensor 
proprius  pollicis  and  the  tendons  to  be  divided. 

The  usual  precautions  are  observed.  The  blade  is  guided 
beneath  the  tendons,  and  the  operator  cuts  towards  the  skin. 
The  assistant  should  take  more  care  to  prevent  the  foot  from 
falling  suddenly  after  the  tenotomy  than  to  put  the  tendons 
upon  the  stretch  during  the  section. 

The  loiife  must  be  kept  close  to  the  tendons,  and  as  super- 
ficial as  possible. 

At  the  ankle  the  anterior  tibial  vessels  lie  beneath  the 
extensor  proprius  pollicis.  On  the  dorsum  of  the  foot  the 
artery  hes  to  the  outer  side  of  that  tendon. 

If  the  knife  be  not  allowed  to  pass  deeply,  the  blood-vessels 
are  in  no  great  danger. 

Hamstring  Tendons. — The  biceps  tendon  can  be  very 
readily  felt  upon  the  outer  side  of  the  popHteal  space.  Just 
behind  it,  and  along  its  inner  border,  lies  the  peroneal  nerve, 
which  can  be  easily  defined  and  rolled  under  the  finger. 

Of  the  semi-tendinosus  and  semi-membranosus,  the  former 
tendon  is  the  nearer  to  the  middle  line  of  the  space,  is  more 


768  OPERATIVE    SUBGEEY. 

superticial,  more  distinct,  and  more  cord-like.  The  latter 
tendon  is  the  most  deeply  placed  of  the  three  hamstrings,  and 
is  of  large  size. 

These  tendons  are  most  conveniently  severed  just  above 
the  line  of  the  knee-joint,  and  on  a  level  with  the  most 
prominent  part  of  the  condyles  of  the  femur. 

Biceps. — The  patient  should  he  as  far  as  possible  upon  the 
face,  so  that  the  popliteal  space  might  be  well  exposed. 

The  surgeon  may  stand  upon  the  inner  side  of  the  Umb  in 
the  case  of  either  the  right  or  the  left  tendon.  If  he  place 
himself  to  the  outer  side  of  the  extremity,  he  will  face  the 
patient  when  dealing  with  the  left  leg,  and  have  his  back  to 
the  patient  when  dealing  with  the  right. 

The  leg  is  steadied  by  an  assistant.  With  a  sharp-pointed 
tenotome  a  puncture  is  made  directly  over  the  tendon,  and 
the  instrument  is  passed  vertically  downwards  on  the  inner 
side  of  the  tendon,  and  is  withdrawn  when  it  has  passed  a 
little  way  beyond  it. 

The  blunt  point  is  now  introduced,  and  following  the  same 
line  is  passed  vertically  between  the  tendon  and  the  nerve. 
When  it  has  just  passed  beyond  the  tendon,  the  blade  is 
turned  outwards,  the  handle  brought  as  nearly  horizontal  as 
possible,  and  the  point  passed  beneath  the  biceps  until  it  may 
be  felt  upon  the  outer  side.  * 

The  tendon  is  then  divided  by  cutting  towards  the  skin, 
which  is  guarded  with  the  left  forefinger  in  the  usual  way. 
During  the  introduction  of  the  tenotomes  and  the  cutting  of 
the  tendon  the  biceps  should  be  kept  upon  the  stretch.  As 
the  knife  is  withdrawn  the  limb  should  be  flexed. 

If  care  be  not  taken,  the  knife  may  shp  through  the  skin 
when  the  tendon  gives  with  a  snap. 

In  the  conditions  for  Avhich  this  operation  is  usually 
performed  the  contracted  biceps  tendon  is  drawn  away  from 
the  nerve,  and  a  wider  interval  than  the  normal  separates  the 
two  structures. 

After  the  tenotomy  the  nerve  may  spring  into  view, 
and  may  be  mistaken  for  an  undivided  portion  of  the 
tendon. 

IJoth   in   the  class-room  and  in   practice   I   have  seen  a 


TENOTOMY.  760 

prominent  and  cord-like  ilio-tibial  band  divided  in  the  place 
of  the  biceps. 

In  some  thin  and  muscular  subjects  the  lower  portion  of 
this  fascial  band  may  feel  very  tendon-like. 

Numerous  contracted  bands  of  fascia  may  come  into 
view  after  tenotomy  of  the  biceps  for  contracted  knee.  Some 
may  need  division.  They  are,  however,  better  left  alone, 
as  they  usually  yield  under  extension,  and  in  dealing  with 
thein  by  tenotomy  unexpected  vessels  may  be  wounded. 

Semi-tendinosus  and  Semi-membranosus.  —  The  same 
observations  as  have  been  applied  to  the  biceps  apply 
generally  to  these  tendons.  They  are  most  conveniently 
divided  exactly  opposite  the  spot  selected  for  tenotomy  of 
the  biceps. 

The  tenotome  is  introduced  upon  the  outer  side  of  the 
tendon,  and  is  passed  beneath  it.  The  steps  of  the  little 
operation  need  not  be  repeated. 

In  one  case  Mr.  Jacobson  met  with  "most  profuse" 
haemorrhage  in  dividing  the  semi-membranosus  tendon  in  a 
girl  of  sixteen.  He  considered  that  the  bleeding — which  was 
checked  b}^  pressure — proceeded  from  the  superior  internal 
articular  artery. 

TREATMENT  OF  DUPUYTREN'S  CONTRACTION. 

The  exact  anatomy  of  the  palmar  fascia  should  be  borne 
in  niind,  and  especially  the  manner  in  which  the  digital 
processes  of  the  fascia  are  disposed  of,  and  the  connections  of 
the  ultimate  slips  of  the  fascia  with  the  integument  of  the 
tingers. 

The  pathology  of  Dupuytren's  contraction  need  not  here 
be  dwelt  upon.  It  is  for  the  relief  of  this  condition  that 
division  of  the  palmar  fascia  is  usually  practised. 

There  are  two  methods  of  dealing  with  the  contracted 
bands — the  subcutaneous  method  and  the  open  method. 
The}'^  are  illustrated  by  the  two  operations  described  below. 

1.  Adams'  Operation. — This  consists  in  the  division  of 
the  bands  of  fascia  by  the  subcutaneous  method,  the  sections 
being  made  at  many  points.  The  treatment  of  Dupuytren's 
contraction  by  subcutaneous  division  of  the  bands  of  fascia 

X    X 


770  OPERATIVE   SUBGEBY. 

appears  to  have  originated  with  Sir  Astley  Cooper.  In  his 
Avork  on  "  Dislocations  and  Fractures  "  (New  Ed.,  1842,  page 
511),  he  "WTites  : — "  When  the  pahnar  aponeurosis  is  the  cause 
of  the  contraction,  and  the  contracted  band  is  narrow,  it  may 
■with  advantage  be  divided  by  a  pointed  bistoury,  introduced 
through  a  very  small  woimd  in  the  integument.  The  finger 
is  then  extended,  and  a  splint  is  applied  to  preserve  it  in  a 
straight  position." 

The  lingers  usually  concerned  in  the  contraction  are  the 
ring  and  little  fingers. 

Operation. — A  very  fine  and  narrow  tenotome  is  em- 
ployed, which  is  introduced  between  the  skin  and  the  fascia, 
and  is  made  to  divide  the  band  by  cutting  towards  the  depths 
of  the  palm,  i.e.,  from  the  skin.  The  points  selected  for  the 
operation  are  spots  where  the  skin  of  the  palm  is  free  from 
attachment  to  the  fascia.  The  knife  is  introduced  at  right 
angles  to  the  line  of  the  contracted  band,  and  the  bent 
fingers  are  put  well  upon  the  stretch  when  the  section  is 
being  made. 

Care  must  be  taken  not  to  dip  the  point  of  the  tenotome 
into  the  deeper  parts  of  the  palm,  and  to  divide  the  fascia, 
and  the  fascia  only.  The  situation  of  the  palmar  arteries 
must  of  course  be  regarded. 

Multiple  punctures  are  needed.  In  an  ordinary  case — in 
which  two  fingers  are  involved — from  six  to  nine  punctures 
will  usually  be  required. 

These  punctures  concern  the  palmar  bands,  and  it  is  easy, 
by  dividing  them,  to  overcome  the  flexion  of  the  metacar23o- 
phalangeal  joints.  The  contraction  that  may  remain  in  the 
fingers,  and  that  will  be  limited  to  the  first  inter-phalangeal 
joint,  is  not  so  easily  coiTccted.  It  may  be  relieved  by  minute 
subcutaneous  divisions  of  the  fascia,  carried  out  with  gi-eat  care 
in  the  region  of  the  web.  It  is  needless  to  say  that  with  the 
fascial  bands  in  this  position  the  digital  arteries  and  nerves 
are  closely  associated. 

The  attemj^t  to  overcome  at  once  all  deformity  of  the 
finger  should  not  be  pressed  too  far,  but  Adams'  splint,  with 
rack-and-pinion  movements  opposite  the  metacarpo-phalan- 
geal  and  inter-phalangeal  joints,  should  be  applied,  and  the 
deformity  be  gradually  overcome. 


TREATMENT  OF  DUPUYTBEN'S   CONTRACTION.      711 

In  any  case  a  splint  must  be  worn  for  many  weeks.  Tlie 
little  punctures  are  dusted  with  iodoform,  and  dressed  with 
cotton-wool. 

In  severe  instances  of  the  deformity  a  digital  nerve  has 
been  either  divided  or  torn,  with  the  result  that  much  pain 
has  followed,  or  a  little  sloughing  has  occurred  at  the  tip  of 
the  liufifer. 

This  operation  has  afforded  very  ftiir  results,  but  it  has 
been  followed  by  a  tendency  to  relapse,  and  so  far  as  my  own 
experience  goes  is  neither  so  successful  nor  so  sure  as  the 
treatment  by  the  open  method  about  to  be  described.  This 
point  is,  however,  discussed  more  fully  on  page  773. 

2.  Hardie's  Modification  of  Goyraud's  Operation. — 
Goyraud  (Schmidt's  Jahrbucher,  1835,  page  248)  made  a  longi- 
tudinal incision  in  the  skin  in  the  long  axis  of  the  contracted 
band,  which,  when  exposed,  was  divided  transversely.  This 
operation  was  an  improvement  upon  the  open  method  of 
Dupuytren,  Avho  divided  both  skin  and  fascia  by  a  simple 
transverse  cut.  It  followed  that  when  the  deformity  was 
corrected  the  wound  gaped  very  considerably,  and  was,  indeed, 
drawn  quite  asunder. 

The  following  is  Mr.  Hardie's  description  {Med.  Chron., 
vol.  i.,  page  9) : — 

"  Esmarch's  tourniquet  having  been  applied,  an  in- 
cision is  begun  half  an  mch  above  the  principal  transverse 
fold  of  the  palm,  immediately  over  the  tense  bridle  of  fascia 
proceeding  to  the  finger  mainly  involved.  This  is  carried 
along  the  bridle  to  a  little  beyond  the  base  of  the  last 
phalanx  which  is  affected.  The  lips  of  the  incision  havmg 
been  opened  up,  the  knife  is  then  carried  close  to  the 
bridle  along  its  whole  extent,  so  as  to  separate  from  it  the 
adjacent  skin,  cellular  tissue,  and  fat,  first  on  one  side,  and 
then  on  the  other.  In  doing  this,  it  is  necessary  to  go 
some  depth  near  the  upper  end  of  the  incision,  so  as  to 
divide  the  little  bands  which  attach  the  Aveb  of  the  finirer 
to  the  processes  of  fascia  inserted  into  the  sides  of  the  first 
phalanx.  This  dissection  having  been  completed,  the  tense 
bridle  of  foscia,  now  almost  isolated,  is  cut  across  at  the 
upper  end  of  the  incision.  This  immediately  permits  of 
an  almost  complete  extension  of  the  first  phalanx.  Further 
X  X  2 


772  OPEBATIVE    SUBGEEY. 

transverse  incisions  are  then  made  opposite  the  middle  of 
the  first  and  second  phalanges,  as  the  case  may  require. 
The  knife  is  then  applied  to  any  portion  of  the  fascia  that 
seems  to  prevent  complete  extension  of  the  fingers.  Some 
portions  may  then  appear  to  be  so  much  isolated,  or  may 
project  so  much,  that  they  may  be  cut  out  entirely.  The 
other  fingers  of  the  same  hand  are  then,  in  their  turn, 
similarly  treated.  Complete  capabihty  of  immediate  ex- 
tension is  to  be  secured.  The  tourniquet  is  then  removed, 
but  although  the  bleeding  will  be  very  smart,  it  is  not  likely 
that  any  vessels  will  be  seen  which  can  be  secured. 

"  I  then  lay  a  catgut  or  horse-hair  drain  along  the  extent 
of  the  wound,  and  bring  the  edges  of  the  latter  accurately 
together  with  silver  wire.  A  large  pad  of  antiseptic  dressmg 
is  applied,  and  the  fingers  are  bandaged  to  a  straight  splint. 
I  regTet  to  have  to  use  a  drain,  but  the  bleeding  is  so  free 
that  I  think  it  a  desirable  precaution.  It  should  be  re- 
moved next  day,  and  the  dressing  re-applied  so  as  to  exert 
some  pressure  on  the  part.  Should  nothing  untoward  occur, 
it  should  be  left  undisturbed  for  a  week,  when  it  is  to  be 
expected  that  sound  union  will  have  taken  place.  The 
stitches  are  removed,  and  subsequent  treatment  will  consist 
in  manipulation  of  the  fingers  and  the  use  of  the  splint 
for  two  or  three  weeks  longer." 

I  have  carried  out  this  operation  in  five  cases,  with  a 
perfectly  satisfactory  result  in  each  instance.  I  do  not  apply 
a  tourniquet,  and  believe  that  in  consequence  of  the  after- 
oozing  it  does  not  affect  the  loss  of  blood.  The  bleeding 
is  not  inconsiderable,  but  it  ceases  readily.  I  have  never 
found  it  necessary  to  use  a  drain.  T  have  m  each  case 
excised  the  bar  of  contracted  fascia,  or  as  much  of  it  as 
was  easily  and  safely  removed.  I  have  found  that  it  is 
scarcely  possible  to  adjust  the  edges  of  the  wound  accurately. 
The  incision  usually  gapes  a  little.  It  heals  slowly  but 
soundly,  and  without  any  noticeable  degree  of  suppuration. 
There  is  generally  a  little  area  left  which  closes  by  gi'anula- 
lion.  Catgut  or  fine  silkAvorm-gut  sutures  were  employed 
in  each  instance.  The  wound  was  well  dusted  with  iodoform 
and  dressed  with  a  sponge.  The  splint  was  in  each  of  the 
cases  worn  for  a  month.     After  that  period  the  patient  was 


TENOTOMY.  773 

advised  to  rub  and  kne;ul  the  affected  palm  and  fingers 
daily,  and  to  frequently  practise  passive  and  active  extension 
of  the  involved  digits. 

The  most  strict  antiseptic  precautions  should  be  observed 
throughout. 

Comment. — Of  the  two  operations  the  latter  is  cer- 
tainly the  more  severe.  It  carries  with  it  such  slight 
risks  as — at  the  present  day — attend  an  open  wound.  The 
healing  of  the  wound  may  be  slow.  There  may  be  some 
swelling  of  the  hand,  and  some  pain.  These  are  perhaps 
the  main  arguments  against  the  measure.  On  the  other 
hand,  there  are  advantages  attending  an  open  wound.  The 
surgeon  does  not  cut  in  the  dark,  the  operation  area  is  well 
exposed,  and  the  contracted  bands  can  not  only  be  divided 
Avith  ease  and  certainty,  but  can  be  entirely  removed.  The 
skin,  moreover,  is  very  freely  liberated  over  the  whole  of  the 
ftfi'ected  district.  The  after-treatment  is  comparatively  simple 
ind  of  short  duration.  The  results  so  far  appear  to  have 
been  eminently  satisfactory. 

In  Adams'  operation  the  actual  operative  measure  is 
certainly  shght,  and  the  wound  made  may  be  practically 
disregarded.  The  after-treatment  is,  however,  tedious.  The 
principal  importance  attaches  to  the  use  of  the  splint,  to 
"  gradual,  quiet,  and  persevering  extension,"  so  long  continued 
as  to  lead  to  atrophy  of  the  divided  fascial  bands.  The 
adhesions  of  the  contracted  fascia  to  the  skin  are  left  un- 
touched. The  after-treatment  is  such  that  the  procedure 
is  but  mdift'erently  suited  to  hospital  practice  ;  and  although 
admirable  results  have  been  claimed  for  the  operation,  still 
many  examples  of  relapse  are  forthcoming. 

DIVISION   OF   THE   STERNO-MASTOID   MUSCLE. 

This  muscle,  or  a  portion  of  it,  is  divided  just  above  its 
origin  in  certain  cases  of  wry-neck.  Sometimes  division  of 
the  sternal  tendon  of  the  muscle  suffices. 

The  tenotomy  is  best  carried  out  about  one-fourth  of  an 
inch  above  the  upper  border  of  the  clavicle  and  sternum. 

The  sterno-mastoid  is  in  this  situation  covered  by  the 
cervical  fascia,  and  is  crossed  by  the  supra-sternal  nerve.  The 
anterior  jugular  vein  passes  behind  it,  just  above  the  clavicle. 


774  OPERATIVE    SUBGEBY. 

and  is  in  danger  of  being  wounded.  This  vein  is,  moreover, 
subject  to  considerable  variation.  The  external  jugular  vein 
is  in  close  relation  with  the  posterior  or  outer  border  of 
the  muscle. 

The  patients  subjected  to  the  operation  are  usually 
children ;  the  muscle  is  prominent,  and  has  by  its  con- 
tracted position  been  somewhat  carried  away  from  the 
subjacent  vessels.  It  is,  moreover,  not  infrequently  con- 
verted into  a  comparatively  narrow  fibrous  cord. 

Tenotomy  of  a  normal  sterno-mastoid  muscle  would  be 
a  dangerous  and  a  somewhat  difficult  operation,  but  the 
same  degree  of  danger  and  difficulty  does  not  attend  the 
tenotomy  as  it  is  carried  out  in  practice. 

The  division  of  the  muscle  in  an  adult  body  in  an 
operative  surgery  class  can  be  scarcely  considered  to  re- 
present the  procedure  which  is  carried  out  upon  the  living 
subject. 

Operation. — The  head  and  shoulders  are  well  raised,  and 
the  trunk  is  brought  close  to  the  head  of  the  table.  The 
operation  will  be  described  as  it  would  apply  to  the  muscle 
of  the  right  side. 

The  surgeon  stands  upon  the  affected  side,  and  facing 
the  patient.  An  assistant  placed  at  the  opposite  side  of  the 
table  so  holds  the  head  as  to  place  the  muscle  upon  the 
stretch. 

The  sternal  and  clavicular  portions  of  the  muscle  should 
be  divided  separately. 

With  a  sharp-pointed  tenotome  a  very  small  vertical 
incision  is  made  along  the  inner  or  anterior  border  of  the 
muscle  (the  sternal  tendon).  The  fascia  is  divided,  and  the 
tendinous  margin  is  clearly  reached.  A  blunt-pointed  teno- 
tome is  now  introduced,  is  passed  down  to  the  tendon  and 
then  behind,  and  is  thrust  along  horizontally  and  on  the  flat, 
until  its  point  can  be  felt  in  the  gap  between  the  clavicular 
and  sternal  portions  of  the  muscle.  It  must  be  kept  as  close 
to  the  muscle  as  possible. 

The  edge  is  now  turned  towards  the  tendon,  which  is 
divided  by  cutting  towards  the  skin. 

The  surgeon's  left  forefinger  is  placed  as  a  guard  over  the 
integument  covering  the  site  of  the  tenotomy. 


TENOTOMY.  775 

The  sharp  tenotome  is  in  like  manner  entered  at  the 
posterior  or  outer  border  of  the  muscle,  and  the  blunt  instru- 
ment introduced  and  manipulated  in  the  same  way.  The 
clavicular  part  of  the  muscle  is  then  divided  in  the  same 
manner  as  was  the  sternal  portion.  It  will  be  noticed  that,  to 
divide  the  former,  the  knife  is  introduced  from  without  in, 
and  to  divide  the  latter  from  within  out.  If  more  convenient, 
the  puncture  for  the  clavicular  portion  may  be  also  made  on 
the  inner  side,  but  this  procedure  involves  a  little  more  risk 
to  the  external  jugular  vein. 

The  surgeon  may  be  disappointed  to  find  that  after  the 
operation  he  is  still  unable  to  entirely  correct  the  deformity. 
This  will  depend  rather  upon  coincident  contractions  of  the 
cervical  fascia  and  the  scalene  muscles,  than  upon  an  in- 
sufficient section  of  the  sterno-mastoid. 

In  dealing  with  the  left  muscle,  the  operator  will  find  it 
convenient  to  stand  beyond  the  upper  end  of  the  table  and 
lean  over  the  patient's  head  to  operate  (i.e.,  he  will  face  the 
patient's  feet) ;  or  he  may  take  up  a  corresponding  position  to 
that  described  in  dealing  with  the  right  side,  and  may  cut 
both  portions  of  the  muscle  through  punctures  made  on  the 
outer  or  posterior  side  of  the  part  to  be  divided,  commencing 
with  the  clavicular  head  of  the  muscle. 

Some  surgeons  recommend  the  following  method  : — 

An  incision  is  made  at  the  anterior  or  inner  border  of  the 
muscle,  and  through  this  a  grooved  director  is  passed 
beneath  the  muscle,  until  its  point  can  be  felt  at  the  posterior 
or  outer  border.  A  narrow  probe-pointed  bistoury  is  now 
introduced  along  the  groove  of  the  director,  and  the  muscle  is 
divided  by  cutting  from  the  posterior  to  the  anterior  border, 
and  from  the  deep-lying  parts  towards  the  skin. 

This  method  is  suited  for  the  normal  muscle,  and  for  the 
operation  as  it  is  performed  in  the  class-room ;  but  it  is  not 
necessary  in  dealing  with  the  usual  cases  requiring  the  opera- 
tion in  actual  practice. 

END   OF  VOL.   L 


RD32f72l892C:i7r"''' 

A  manual  of  operative  sure 


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T72 


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